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Benefit options EPO plan effective...

Benefit options EPO plan effective 2009

EPO PLAN
EFFECTIVE OCTOBER 1, 2009
www.benefitoptions.az.gov
AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time
for clarification purposes without prior notice.
AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
TABLE OF CONTENTS
ARTICLE 1 ESTABLISHMENT OF PLAN 1
ARTICLE 2 ELIGIBILITY AND PARTICIPATION 2
ARTICLE 3 PRE-CERTIFICATION AND NOTIFICATION 16
FOR MEDICAL SERVICES AND PRESCRIPTION MEDICATIONS
ARTICLE 4 CASE MANAGEMENT / DISEASE MANAGEMENT 23
ARTICLE 5 TRANSITION OF CARE 26
ARTICLE 6 OPEN ACCESS TO NETWORK PROVIDERS 27
ARTICLE 7 SCHEDULE OF MEDICAL BENEFITS 28
ARTICLE 8 PRESCRIPTION DRUG BENEFITS 60
ARTICLE 9 EXCLUSIONS AND GENERAL LIMITATIONS 66
ARTICLE 10 COORDINATION OF BENEFITS AND 72
OTHER SOURCES OF PAYMENT
ARTICLE 11 CLAIM FILING PROVISIONS AND 81
APPEALS PROCESS
ARTICLE 12 PLAN MODIFICATION, AMENDMENT, AND 89
TERMINATION
ARTICLE 13 ADMINISTRATION 90
ARTICLE 14 MISCELLANEOUS 93
ARTICLE 15 PLAN IDENTIFICATION 94
ARTICLE 16 DEFINITIONS 96
ARTICLE 1
ESTABLISHMENT OF PLAN
1.1. PURPOSE
The Plan Sponsor established this Plan to provide for the payment or reimbursement of covered medical expenses incurred by Plan Members.
1.2. EXCLUSIVE BENEFIT
This Plan is established and shall be maintained for the exclusive Benefit of eligible Members.
1.3. COMPLIANCE
This Plan is established and shall be maintained with the intention of meeting the requirements of all pertinent laws. Should any part of this Plan Description, for any reason, be declared invalid, such decision shall not affect the validity of any remaining portion, which remaining portion shall remain in effect as if this Plan Description has been executed with the invalid portion thereof eliminated.
1.4. LEGAL ENFORCEABILITY
The Plan Sponsor intends that terms of this Plan, including those relating to coverage and Benefits provided, are legally enforceable by the Members, subject to the Employer’s retention of rights to amend or terminate this Plan as provided elsewhere in this Plan Description.
1.5. NOTE TO MEMBERS
This Plan Description describes the circumstances when this Plan pays for medical care. All decisions regarding medical care are up to a Member and his Physician. There may be circumstances when a Member and his Physician determine that medical care, which is not covered by this Plan, is appropriate. The Plan Sponsor and the Third Party Claim Administrator do not provide or ensure quality of care.
Each network contracts with the in-network providers under this Plan. These providers are affiliated with the EPO Networks and Travel Network and do not have a contract with the Plan Sponsor or Third Party Claim Administrator.
1 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
ARTICLE 2
ELIGIBILITY AND PARTICIPATION
2.1. Eligibility
The Plan is administered in accordance with Section 125 Regulations of the Internal Revenue Code and the Arizona Administrative Code.
Please see ARTICLE 16 for definitions of the terms used below.
The Benefit Services Division will provide potential members reasonable notification of their eligibility to participate in the Plan as well as the terms of participation.
Both the Benefit Services Division and the Medical Network Vendor have the right to request information needed to determine an individual’s eligibility for participation in the Plan.
2.2. Member eligibility
Eligible employees, eligible retirees, and eligible former elected officials may participate in the Plan.
In certain situations, an individual may be eligible to enroll as both a member and a dependent. This individual should enroll either as a member or as a dependent but never both.
2.3. Dependent eligibility
Members’ spouses, domestic partners, unmarried children, and older children may participate in the Plan.
In certain situations, an individual may be eligible to enroll as both a member and a dependent. This individual should enroll either as a member or as a dependent but never both.
In certain situations, an individual may be eligible to participate as a dependent of more than one member. This individual should be enrolled as the dependent of only one of the members.
2.4. Continuing eligibility through COBRA
See Section 4 of this article.
2 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
2.5. Non-COBRA continuing eligibility
The following individuals are eligible for continuing coverage under the Plan.
1. Eligible employee on leave without pay
An employee who is on leave without pay for a health-related reason that is not an industrial illness or injury may continue to participate in the Plan by paying both the state and employee contribution. Eligibility shall terminate on the earliest of the employee:
•
Receiving long-term disability benefits that include the benefit of continued participation;
•
Becoming eligible for Medicare coverage; or
•
Completing 30 months of leave without pay.
An employee who is on leave without pay for other than a health-related reason may continue to participate in the Plan for a maximum of six months by paying both the state and employee contributions.
2. Surviving dependent(s) of insured retiree
Upon the death of a retiree insured under the Plan, the surviving dependents are eligible to continue coverage under the Plan, provided each was insured at the time of the member’s death, by payment of the retiree premium.
If the spouse/domestic partner survives, he/she, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse/domestic partner may be continued indefinitely.
In the case where children/older children, who are eligible dependents of the surviving spouse/domestic partner, survive, they may continue participation in the Plan if enrolled by the surviving spouse/domestic partner as allowed under section 2.3.
In the case where children/older children survive but no spouse/domestic partner survives or the children/older children are not eligible dependents of the spouse/domestic partner, each child/older child, for purposes of Plan administration, will be reclassified as a
3 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
member. As such, each child/older child may enroll dependents as allowed under section 2.3. In this circumstance, coverage for each surviving child/older child may be continued indefinitely.
Please note that a dependent not enrolled at the time of the member’s death may not enroll as a surviving dependent.
3. Surviving spouse/child of insured employee eligible for retirement under the Arizona State Retirement System
Upon the death of an insured employee meeting the criteria for retirement under the Arizona State Retirement System, the surviving spouse and children, provided each was enrolled at the time of the member’s death, are eligible to continue participation in the Plan by payment of the retiree premium.
If the insured spouse survives, he/she, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse may be continued indefinitely.
In the case where insured children, who are eligible dependents of the surviving spouse, survive, they may continue participation in the Plan if enrolled by the surviving spouse as allowed under section 2.3.
In the case where insured children survive but no spouse survives, each child, for purposes of Plan administration, will be reclassified as a member. As such, each child may enroll dependents as allowed under section 2.3. In this circumstance, coverage for each surviving child may be continued indefinitely.
Please note that a child/spouse not enrolled as a dependent at the time of the member’s death may not enroll as a surviving child/spouse.
4. Surviving spouse of elected official or insured former elected official
Upon the death of a former elected official insured under the Plan, the surviving spouse may continue participation in the Plan, provided that he/she was enrolled at the time of the member’s death, by payment of the retiree premium. The surviving spouse, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse may be continued indefinitely.
4 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
Please note that a spouse not enrolled at the time of the former elected official’s death may not enroll as a surviving spouse.
Upon the death of an elected official who would have become eligible for coverage upon completion of his/her term, the surviving spouse may continue participation in the Plan, provided that he/she was enrolled at the time of the elected official’s death, by payment of the retiree premium. The surviving spouse, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under Section 2.3. Coverage for the surviving spouse may be continued indefinitely.
Please note that a spouse not enrolled at the time of the elected official’s death may not enroll as a surviving spouse.
2.6. Eligibility audit
The Benefit Services Division may audit a member’s documentation to determine whether an enrolled dependent is eligible according to the Plan requirements. This audit may occur either randomly or in response to uncertainty concerning dependent eligibility.
Both the Benefit Services Division and the Medical Network Vendor have the right to request information needed to determine an individual’s eligibility for participation in the Plan.
2.7. Grievances related to eligibility
Individuals may file a grievance with the Director of the Department of Administration regarding issues related to eligibility. To file a grievance, the individual should submit a letter to the Director that contains the following information:
•
Name and contact information of the individual filing the grievance;
•
Nature of the grievance; and
•
Nature of the resolution requested
The Director will provide a written response to a grievance within 60 days.
5 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
2.8. Enrollment procedures and commencement of coverage
New enrollments or coverage changes will only be processed in certain circumstances. Those circumstances are described below.
2.9. Initial enrollment
Once eligible for coverage, potential members have 31 days to enroll themselves and their dependents in the Plan.
It should be emphasized that coverage begins only after an individual has successfully completed the enrollment process. Documentation may be required.
The table below lists pertinent information related to the initial enrollment process.
Category
Must enroll within
31 days of
Enrollment
contact
Coverage begins
on the1
Eligible state employee
date of hire
Agency liaison
first day of first pay period after completion of enrollment
Eligible university employee
date of hire
Human resources office
Please contact the appropriate human resources office
Eligible participating political subdivision employee
date of hire
Human resources office
Please contact the appropriate human resources office
Eligible retiree
date of retirement
Benefit Services Division
first day of first month after completion of enrollment2
Eligible former elected official
date of leaving office or retiring
Benefit Services Division
first day of first month after completion of enrollment
1 Under no circumstance will coverage for a dependent become effective prior to the member’s coverage becoming effective.
6 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
2 For state employees entering retirement and their dependents, coverage begins the first day of the first pay period following the end of coverage as a state employee. This results in no lapse in coverage.
clarification purposes without prior notice.
7 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
Category Must enroll within
31 days of
Enrollment
contact
Coverage begins
on the1
Surviving spouse of elected official or eligible former elected official
date of death
Benefit Services Division
first day of first month after completion of enrollment
2.10.
Open enrollment
Before the start of a new plan year, members are given a certain amount of time during which they may change coverage options. Potential members may also elect coverage at this time. This period is called open enrollment.
In general, open enrollment for eligible employees, retirees and former elected officials is held in August.
At the beginning of each year’s open enrollment period, enrollment booklets are provided to those eligible for coverage under the Plan. These booklets contain information regarding changes in benefits as well as whether a current member is required to re-elect his/her coverage during open enrollment (called a “positive” open enrollment).
Elections must be made before the end of open enrollment. Those elections – or the current elections, if no changes were made and it was not a positive open enrollment - will be in effect during the subsequent plan year.
Coverage for all groups begins on the first day of the new plan year.
It should be emphasized that coverage options change only after an individual has successfully completed the enrollment process. Documentation may be required.
2.11.
Qualified life event enrollment
If a qualified life event occurs, members have 31 days3 to enroll or change coverage options.
Changes made as a result of a qualified life event must be consistent with the event itself. For example, if a dependent child gets married,
3 Pursuant to the Children’s Health Insurance Program (CHIP) Reauthorization Act, individuals who lose Medicaid or CHIP coverage due to ineligibility have 60 days to request enrollment.
clarification purposes without prior notice.
coverage for that child may be immediately discontinued but coverage for another dependent child may not be discontinued until the following open enrollment period or until a qualified life event affecting the second child occurs.
It should be emphasized that coverage options change only after an individual has successfully completed the enrollment process. Documentation may be required.
State employees should contact the appropriate agency liaison when they choose to change coverage options as a result of a qualified life event. University and political subdivision employees should contact the appropriate human resources office. Retirees and former elected officials should contact the Benefit Services Division.
For state employees, most coverage changes become effective on the first day of the first pay period after completion of enrollment. For retirees and former elected officials, most coverage changes become effective on the first day of the first month after completion of enrollment. University and political subdivision employees should contact the appropriate human resources office for information regarding the effective date of coverage changes.
The table below lists pertinent information related to the qualified life event enrollment process. It should be noted that not all qualified life events are listed below.
Type of event
Must enroll/change
coverage within
31 days of:
Coverage/change
in coverage begins
on the4:
Marriage
date of the event
See above
Death of dependent
date of the event
See above
Divorce, annulment, or legal separation
date of the event
See above
8 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
4 University and political subdivision employees should contact the appropriate human resources office for information regarding effective date of coverage changes.
clarification purposes without prior notice.
9 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
Type of event Must enroll/change
coverage within
31 days of:
Coverage/change
in coverage begins
on the4:
Employment status change (beginning employment, termination, strike, lockout, beginning/ ending FMLA, full-time to part-time)
date of the event
See above
Change in residence
date of the event
See above
Loss/gain of dependent eligibility (other than listed below)
date of the event
See above
Newborn5
date of birth
date of birth6
Recently adopted child
date of placement for adoption
date of adoption7
Child recently placed under legal guardianship
date member granted legal guardianship
date member granted legal guardianship7
Child recently placed in foster care
date of placement in foster care
See above
2.12.
Change in cost of coverage
If the cost of benefits increases or decreases during a plan year, the Benefit Services Division may, in accordance with plan terms, automatically change your elective contribution.
When the Benefit Services Division determines that a change in cost is significant, a member may either increase his/her contribution or elect less-costly coverage.
2.13.
Termination of coverage
Coverage for all members/dependents ends at 11:59 p.m. on the date the Plan is terminated. Termination of coverage prior to that time is described in the table below.
5 Born to member or member’s legal spouse.
6 Coverage ends on 31st day after date of birth if member does not enroll newborn in the Plan.
7 Child recently adopted, placed under legal guardianship, or placed in foster care covered from date of adoption only if member subsequently enrolls child in the Plan. clarification purposes without prior notice.
Category
Coverage ends at 11:59 p.m.
on the earliest of:
Eligible state/university employee
•
last day of the pay period for/in which the member:
􀂾􋹭
makes last contribution;
􀂾􋹦
fails to meet the requirements for eligibility; or
􀂾􋹢
becomes an active member of the armed forces of a foreign country; or
•
last day member is eligible for extension of coverage.
Eligible participating political subdivision employee
Please contact the appropriate human resources office
Eligible retiree8/former elected official
•
last day of the month for/in which the member:
􀂾􋹭
makes last premium payment; or
􀂾􋹦
fails to meet the requirements for eligibility.
Eligible long-term disability recipient
•
last day of the month in which the disability benefit ends.
Eligible dependent
•
last day of the pay period in which the dependent child ceases to be a full-time student9;
•
day before dependent child/older child reaches the limiting age;
•
day the dependent:
􀂾􋹤
dies;
􀂾􋹬
loses eligibility for reason other than limiting age; or
􀂾􋹢
becomes an active member of the armed forces of a foreign country; or
•
day the member:
􀂾􋹩
is relieved of a court-ordered obligation to furnish coverage for a dependent child; or
􀂾􋹩
is no longer covered.
10 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
8 excluding long-term disability recipient
clarification purposes without prior notice.
11 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
Category Coverage ends at 11:59 p.m.
on the earliest of:
Eligible employee on leave without pay
•
last day of period in which member becomes eligible for:
􀂾􋹬
long-term disability benefits for which there is eligibility to continue coverage under the Plan; or
􀂾􋹣
coverage under Medicare; or
•
30 months after the leave-without-pay period began.
Surviving child/spouse of eligible retiree
•
last day of the period for which the member makes last payment; or
•
day the surviving child fails to be eligible as a child/older child.
Surviving spouse of elected official or eligible former elected official
•
last day of the period for which the member makes last payment.
2.14.
Continuing eligibility through COBRA
Eligibility of enrolled members/dependents
In accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), a member/dependent at risk for losing coverage due to a qualifying event may extend his/her coverage under the Plan for a limited period of time.
To be eligible for COBRA coverage, a member/dependent must be covered under the Plan on the day before the qualifying event. Each covered individual may elect COBRA coverage separately. For example, a dependent child may continue coverage even if the member does not.
Members and dependents would be eligible for COBRA coverage in the event that the state of Arizona files bankruptcy under Title 11 of the U.S. Code.
The table below lists individuals who would be eligible for COBRA coverage if one of the corresponding qualifying events were to occur.
9 If child is not a full-time student for more than one school term, termination is retroactive to the last day of the month in which the full-time status ended. clarification purposes without prior notice.
Category
Duration of COBRA coverage
Qualifying event
Eligible employee, dependent
Up to 18 months10
•
Voluntary or involuntary termination of member’s employment for any reason other than "gross misconduct"; or
•
Reduction in the number of hours worked by member (including retirement)11.
Dependent
Up to 36 months
•
Member dies; or
•
Member and dependent spouse/domestic partner divorce, legally separate, or terminate partnership.
Dependent child/older child
Up to 36 months
•
Dependent child/older child no longer meets eligibility requirements.
2.15.
Subsequent qualifying events
An 18-month COBRA period may be extended to 36 months for a dependent if:
•
Member dies; or
•
Member and dependent spouse/domestic partner divorce, legally separate, or dissolve partnership; or
•
Dependent child/older child no longer meets eligibility requirements.
This clause applies only if the second qualifying event would have caused the dependent to lose coverage under the Plan had the first qualifying event not occurred.
10 If the member and/or dependent is disabled when he/she becomes eligible for COBRA or within the first 60 days of COBRA coverage, duration of coverage may be extended to 29 months. See section 2.4 for special rules regarding disability. 12 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
11 If the member takes a leave of absence qualifying under the Family and Medical Leave Act (FMLA) and does not return to work, the COBRA qualifying event occurs on the date the member notifies ADOA that he/she will not return, or the last day of the FMLA leave period, whichever is earlier.
clarification purposes without prior notice.
2.16.
Eligibility of newly acquired eligible dependents
If the member gains an eligible dependent during COBRA coverage, the dependent may be enrolled in the Plan through COBRA. The member should provide written notification to the Benefit Services Division within 31 days of the qualifying life event. Newly acquired dependents may not enroll in the COBRA coverage after 31 days.
2.17.
Special rules regarding disability
The 18 months of COBRA coverage may be extended to 29 months if a member is determined by the Social Security Administration to be disabled at the time of the first qualifying event or during the first 60 days of an 18-month COBRA coverage period. This extension is available to all family members who elected COBRA coverage after a qualifying event.
To receive this extension, the member must provide the Benefit Services Division with documentation supporting the disability determination within 60 days after the latest of the:
•
Social Security Administration makes the disability determination;
•
Qualifying event occurs; or
•
Date coverage is/would be lost because of the qualifying event.
2.18.
Payment for COBRA coverage
Participants who extend coverage under the Plan due to a COBRA qualifying event must pay 102% of the active premium. Participants whose coverage is extended from 18 months to 29 months due to disability may be required to pay up to 150% of the active premium beginning with the 19th month of COBRA coverage.
COBRA coverage does not begin until payment is made to the COBRA administrator. A participant has 45 days from submission of his/her application to make the first payment. Failure to comply will result in loss of COBRA eligibility.
2.19.
Notification by the member/dependent
Under the law, the Plan must receive written notification of a divorce, legal separation, dissolution of partnership, or child’s/older child’s loss of dependent status, within 60 days of the later of the:
•
Date of the event; or
13 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
•
Date coverage would be lost because of the event.
Notification must include information related to the member and/or dependent(s) requesting COBRA coverage. Documentation may be required.
COBRA coverage cannot be elected if proper notification is not made.
Written notification should be directed to:
ADOA Benefit Services Division
100 N. 15th Avenue, Suite 103
Phoenix, AZ 85007
2.20.
Notification by the Plan
The Plan is obligated to notify each participant of his/her right to elect COBRA coverage when a qualifying event occurs.
2.21.
Electing COBRA coverage
Information related to COBRA coverage and enrollment may be obtained through an agency liaison or by calling ADOA Benefit Services Division at 602-542-5008 or 1-800-304-3687 or by writing to the address provided in Section F.
2.22.
Early termination of COBRA coverage
The law provides that COBRA coverage may, for the reasons listed below, be terminated prior to the 18-, 29-, or 36-month period:
•
The Plan is terminated and/or no longer provides coverage for eligible employees;
•
The premium is not received within the required timeframe;
•
The member enrolls in another group health plan that does not exclude/limit coverage for pre-existing conditions; or
•
The member becomes eligible for Medicare.
For members whose coverage was extended to 29 months due to disability, COBRA coverage will terminate after 18 months or when the Social Security Administration determines that the member is no longer disabled.
14 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
2.23.
Contact information for the COBRA administrator
COBRA-related questions or notifications should be directed to the Benefit Services Division.
2.24.
Certificate of creditable coverage
When COBRA coverage ends, the Medical Network Vendor will send a certificate of creditable coverage. This certificate confirms that each participant was covered under the Plan and for what length of time. The certificate may be used as credit against a new plan’s pre-existing condition limitation.
15 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
ARTICLE 3
PRE-CERTIFICATION AND NOTIFICATION FOR MEDICAL SERVICES AND PRESCRIPTION MEDICATION
3.1.
Pre-Certification and Notification
Pre-certification is the process of determining the Medical Necessity of services before the services are incurred. This ensures that any medical care a member receives meets the Medical Necessity requirements of the Plan. The definition and requirements of Medical Necessity are identified in Article 16. Pre-Certification is initiated by calling the toll-free Pre-Certification phone number shown on your ID card and providing information on the planned medical services. Pre-Certification may be requested by you, your dependent or your Physician. However, the Member is ultimately responsible to ensure Pre-Certification is obtained.
All decisions regarding medical care are up to a Patient and his/her Physician. There may be circumstances when a Patient and his/her Physician determine that medical care, which is not covered by this Plan, is appropriate. The Plan Sponsor and the Third Party Claim Administrator do not provide or ensure quality of care.
Pre-certification should be initiated for specific services are noted in the Plan Description by calling the Medical Network Vendor Customer Service Center and providing information on the planned medical services. The patient or the physician/facility may request pre-certification; however, the member is ultimately responsible to ensure pre-certification is obtained.
If Pre-certification is not obtained before planned medical services are incurred, the submitted claim will held and a letter will be issued notifying you and the provider that pre-certification is required before claim processing can continue. This must be initiated by calling the Medical Network Vendor and providing information on the incurred medical services. If pre-certification is not initiated within 60 days of the first pend letter, the claim will be denied.
3.2.
Treatment by Participating Providers
If you do not Pre-Certify as required above, the Claims Administrator will review the claims submitted for Medical Necessity after the services have been rendered. If the claim is denied based on the plan provisions or Medical Necessity, the member is responsible for payment.
16 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
3.3.
Treatment by Non-Participating Providers
Except in emergency situations, treatment provided by a non-Participating Provider is not covered by the Plan. However, there may be rare circumstances where the Plan will provide coverage for services rendered by a non-Participating Physician (e.g. there is only one specialist who is able to treat your specific disease and that specialist does not contract with the network). The only way you can obtain coverage in these instances is by obtaining Pre-Certification.
3.4.
Medical Services Inpatient Admissions
Pre-Certification for Inpatient admissions refers to the process used to certify the medical necessity and length of any Hospital Confinement as a registered bed patient. Pre-Certification is performed through a utilization review program by a Medical Management Organization with which the State of Arizona has contracted. Pre-Certification should be requested by you, your dependent or an attending physician by calling the Pre-Certification phone number shown on your ID card prior to each inpatient Hospital admission. Pre-Certification should be requested, prior to the end of the certified length of stay, for continued inpatient Hospital Confinement.
You should start the Pre-Certification process by calling the Medical Management Organization prior to an elective admission, prior to the last day approved for a current admission, or in the case of an emergency admission, by the end of the second scheduled business day after the admission. The Medical Management Organization will continue to monitor the confinement until you are discharged from the Hospital. The results of the review will be communicated to the Member, the attending Physician, and the Third Party Claim Administrator.
The Medical Management Organization is an organization with a staff of Registered Nurses and other trained staff members who perform the Pre-Certification process in conjunction with consultant Physicians.
3.5.
Other Services & Supplies
Pre-Certification should be requested for those services that require Pre-Certification. Pre-Certification should be requested by you, your dependent or your physician by calling the toll-free phone number shown your ID card prior to receiving services. Services that should be Pre-Certified include, but are not limited to:
1.
Inpatient services in a hospital or other facility (such as hospice or skilled nursing facility);
17 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
2.
Inpatient maternity services in a hospital or birthing center exceeding the Federally mandated stay limit of 48 hours for a normal delivery or 96 hours for a c-section;
3.
A separate Pre-authorization is required for a newborn in cases where the infant has been diagnosed with a medical condition requiring in-patient services independent of the maternity stay.
4.
Outpatient surgery in a hospital or ambulatory surgery center as required by the Third Party Claims Administrators.
5.
Accidental dental services;
6.
Dental confinements/anesthesia required due to a hazardous medical condition;
7.
Mental/nervous and substance abuse services (both inpatient and outpatient);
8.
Outpatient and ambulatory magnetic resonance imaging (MRI/MRA), PET Scans, ECT, BEAM (Brain Electrical Activity Mapping), Gamma Knife;
9.
Non-emergency ambulance transportation;
10.
Organ transplant services;
11.
Cancer clinical trials;
12.
Chronic Pain management treatment (including biofeedback);
13.
Infusion/IV Therapy in an Outpatient setting to include: Infliximab (Remicade), Alefacept (Amevive), and Etanercept (Enbrel);
14.
Injectable medication in the Physician’s office to include but not limited to Alefacept (Amevive), Etanercept (Enbrel), Sodium Hyaluronate (Hyalgan, Synvisc), Infliximab (Remicade), Omalizumab (Xolair), Lupron, Syranel, Forteo, Lupron Depot;
15.
Home health, including hospice, and parenteral;
16.
Outpatient and ambulatory cardiac testing, angiography, PFT, 23-hour sleep studies, video EEG;
17.
Rental of Durable Medical Equipment which is expected to have a purchase price of $1000 or more;
18.
Purchase of Durable Medical Equipment and prosthetics costing more than $1000;
19.
Foot Orthotic devices and inserts (covered only for diabetes mellitus and any of the following complications involving the foot: Peripheral neuropathy with evidence of callus formation; or history of pre-ulcerative calluses; or history of previous ulceration; or foot deformity; or previous
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amputation of the foot or part of the foot; or poor circulation.);
20.
Repair or replacement of prosthetics;
21.
End Stage Renal Disease services (including dialysis);
22.
Services not available through an in-network provider;
23.
Rehabilitation therapy in excess of 60 visits per Member per Plan Year;
24.
Services which have a potential for a cosmetic component, including but not limited to, blepharoplasty (upper lid), breast reduction, breast reconstruction, ligation (vein stripping), and sclerotherapy.
25.
CAT/CT imagery
26.
Injections given during an office visit that cost over $350.00 per injection.
27.
Cochlear Implants.
28.
Treatment for Autism Spectrum Disorder.
3.6.
Notification of 23-hour observation admissions
While Pre-Certification is not required for 23-hours observation admissions, we encourage you to contact the Medical Management Organization if you will be receiving these services. This will assist in the Pre-Certification process should the admission exceed 23 hours.
3.7.
Notification of maternity services
While Pre-Certification is not required for maternity services in the physician’s office, outpatient, and inpatient within federally mandated stay limits, we encourage you to contact the Medical Management Organization if you will be receiving any maternity services. This will assist in the Pre-Certification process should Inpatient services be required that exceed 48 hours for a normal delivery and 96 hours for a c-section. Notification also enables the Medical Management Organization staff to assist you with education and/or resources to maintain your health during your pregnancy. Inpatient maternity services are subject to a $250.00 maternity delivery co-payment per child. The $250.00 co-payment will be reimbursed if the member enrolls in the health pregnancy program prior to the 12th week of pregnancy and completes the program.
3.8.
Prescription Medications
For the purposes of member safety, certain prescriptions require “prior authorization” or approval before they will be covered, including but not limited to an amount/quantity that can be used within a set timeframe, an age limitation has been reached and/or exceeded or appropriate utilization must be determined. The Pharmacy Benefit Management
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Vendor (PBM), in their capacity as pharmacy benefit manager, administers the clinical prior authorization process.
Clinical Prior Authorization (CPA) may be initiated by the pharmacy, the physician, you, and/or your covered family members by calling the PBM. The pharmacy may call after being prompted by a medication denial stating “Prior Authorization required.” The pharmacy may also pass the information on to you and require you to follow-up.
After the initial call is placed, the Clinical Services Representative obtains information and verifies that the plan participates in a CPA program for the particular drug category. The Clinical Services Representative generates a drug specific form and faxes it to the prescribing physician. Once the fax form is received by the Clinical Call Center, a pharmacist reviews the information and approves or denies the request based on established protocols. Determinations may take up to 48 hours from the PBM’s receipt of the completed form, not including weekends and holidays.
If the prior authorization request is APPROVED, the PBM Clinical Service Representative calls the person who initiated the request and enters an override into the PBM processing system for a limited period of time. The pharmacy will then process your prescription.
If the prior authorization request is DENIED, the PBM Clinical Call Center pharmacist calls the person who initiated the request and sends a denial letter explaining the denial reason. The letter will include instructions for appealing the denial. For more information see the “Appeals Procedures” section of this document.
The criteria for the Prior Authorization program are based on nationally recognized guidelines; FDA approved indications and accepted standards of practice. Each specific guideline has been reviewed and approved by the PBM Pharmacy and Therapeutics (P&T) Committee for appropriateness. Prescription medications that require prior authorization prior to dispensing include but are not limited to:
1.
Anabolic steroids – injectable (Deca-Durabolin®, Virilon IM®);
2.
Anabolic Steroids - Oral (Anadrol-50®, Android Testred®, Oxandrin®, Winstrol®);
3.
Anabolic Steroids – Topical (Androderm®, Androgel®, Testoderm®);
4.
Botulinum Toxins (Myobloc®, Botox®);
5.
Lamisil®;
6.
Sporanox®; and
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Medication(s) included in medication management programs, including but not limited to, an amount or quantity that can be used within a set timeframe or an age limitation, may be subject to prior authorization. Medication Management programs are subject to change and are maintained and updated as medications are FDA approved within the defined therapeutic class and as clinical evidence requires. Medications subjected to prior authorization resulting from medication management programs include, but are not limited to:
1.
Topical Anti-acne products after the age of 24 (e.g. Retin-A®, Avita®, Differin®);
2.
Medications for Attention Deficit Hyperactivity Disorder/ Narcolepsy after the age of 19 (e.g. Dexedrine®, Ritalin®, Cylert®);
3.
Oral Antiemetics beyond defined quantity limitations (e.g. Kyrtil®, Zofran®);
4.
Medications to treat insomnia beyond defined quantity limitations (e.g. Ambien®, Restoril®, Sonata®); and
5.
Medications used to treat migraine headaches beyond defined quantity limitations (e.g. Imitrex®)
A certain class of medications will be managed through the Pharmacy Benefit Management Vendor’s Specialty Pharmacy Program. For more information, on what is covered see the “Specialty Pharmacy” section of this document. Medications that may be included in this program are used to treat chronic or complex health conditions, may be difficult to administer, may have limited availability, and/or may require special storage and handling. A subset of the medications included in the PBM Specialty Pharmacy program requires prior authorization and include, but are not limited to:
1.
Xolair®;
2.
Remicade®, Amevive®, Enbrel®, Kineret®, Humira®, Raptiva®;
3.
Hyalgan ®, Supartz® ,Synvisc®;
4.
Forteo® ;
5.
Lupron®, Synarel®;
6.
Lupron Depot®, Viadur®, Zoladex®, Eligard®, Trelstar®;
7.
Synagis®; and
8.
Growth Hormones.
To confirm whether you need prior authorization and/or to request a prior authorization, call the Pharmacy Benefit Management Vendor listed on your ID card. Please have the information listed below when initiating your request for prior authorization:
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•
Name of your Medication
•
Physician’s Name
•
Physician’s Phone Number
•
Physician’s Fax Number, if available
•
Member ID number (from your card)
•
Rx Group ID number (from your card)
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ARTICLE 4
CASE MANAGEMENT / DISEASE MANAGEMENT AND INDEPENDENT MEDICAL ASSESSMENT
4.1.
Case Management
Case Management is a service provided through an organization contracted with the State of Arizona, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending physician to determine appropriate treatment options which will best meet the patient’s needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis.
Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, some trained in a clinical specialty area such as high risk pregnancy or mental health, and others who work as generalists dealing with a wide range of conditions in general medicine and surgery. In addition, Case Managers are supported by physician advisors who offer guidance on up-to-date treatment programs and medical technology. While the Case Manager may recommend alternate treatment programs and help coordinate needed resources, the patient’s attending physician remains responsible for ordering and guiding the actual medical care.
You, you’re dependent or an attending physician may request Case Management services by calling the toll-free phone number shown on your ID card during normal business hours, Monday through Friday. In addition, the Third Party Claim Administrator or a utilization review program may refer an individual for Case Management.
Each case is assessed to determine whether Case Management is appropriate. You or your Dependent will be contacted by an assigned Case Manager who explains in detail how the program works.
Participation in the program is voluntary – no penalty or benefit reduction is imposed if you do not wish to participate in Case Management.
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Following an initial assessment, the Case Manager works with you, your family and physician to determine the needs of the patient and to identify what alternate treatment programs are available. (For example, in-home medical care in lieu of extended hospital convalescence.) You are not penalized if the alternate treatment program is not followed.
The Case Manager arranges for alternate treatment services and supplies, as needed. (For example, nursing services or a hospital bed and other durable medical equipment for the home.)
The Case Manager also acts as a liaison between the Third Party Claim Administrator, the patient, his or her family and physician as needed. (For example, by helping you to understand a complex medical diagnosis or treatment plan.)
Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient’s needs.
While participation in Case Management is strictly voluntary, Case Management professionals may offer quality, cost-effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.
4.2.
Disease Management
Disease Management is a service provided through an organization contracted with the State of Arizona, which assists Members with treatment needs for chronic conditions. Disease Management is a voluntary program – no penalty or benefit reduction is imposed if you do not wish to participate in Disease Management.
If you are being treated for certain conditions which have been initiated under this program, you will be contacted by the Disease Management staff with further information on the program. The goal of Disease Management is identification of areas in which the staff may assist you with education and/or resources to maintain your health.
4.3.
Independent Medical Assessment
The Plan reserves the right to require independent medical assessments to review appropriateness of treatment and possible alternative treatment options for any member participating on the plan. The individual medical assessments may take place on site or via medical record review and will be carried out by a licensed/board certified
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medical doctor specializing in the area of treatment rendered to the member. Independent medical assessments may be utilized in instances where current treatment is atypical for the diagnosis, where the current treatment is complex and involves many different providers, and/or the current treatment is of high cost to the Plan. If an independent medical assessment is required, the enrolled person will be notified in writing.
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ARTICLE 5
TRANSITION OF CARE
5.1
Transition of Care
If you are a new Member, upon written request to the Medical Management Organization, you may continue an active course of treatment with your current health care provider who is not a Participating Provider and receive in-network benefit levels during a transitional period after the effective date of coverage if one of the following applies:
1.
You have a life threatening disease or condition;
2.
If you have been receiving care and a continued course of covered treatment is Medically Necessary, you may be eligible to receive “transitional care” from the non-Participating Provider;
3.
Entered the third trimester of pregnancy on the effective date of enrollment; or
4.
If you are in your second trimester of pregnancy and your doctor agrees to accept our reimbursement rate and to abide by the Plan’s policies and procedures and quality assurance requirements.
There may be additional circumstances where continued care by a provider no longer participating in the network will not be available, such as when the provider loses his license to practice or retires.
Transitions of Care request forms are available by contacting the Medical Network Vendor Customer Service Center or by visiting their Website.
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ARTICLE 6
OPEN ACCESS TO PROVIDERS
Open access refers to how you “access” physicians. This plan does not require members to designate a Primary Care Physician (PCP) and members may schedule an appointment directly with a specialist of his/her choosing; however, the specialist MUST be contracted within your medical plan provider network.
Members may still choose to maintain a primary relationship with one physician and are encouraged to do so, but are not required to. For assistance finding a health care provider, contact the member services office at the number listed on your ID card.
In order for eligible services to be covered by this plan, it is the member’s responsibility to confirm the facilities, specialists and physicians they use are contracted with his/her medical plan network of providers at the time services are provided.
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ARTICLE 7
SCHEDULE OF MEDICAL BENEFITS
COVERED SERVICES AND SUPPLIES
7.1.
Schedule of Medical Benefits Covered Services and Supplies Chart
It is important to note that all inpatient services, specific outpatient services, and certain prescription medications require Pre-Certification. Please refer to Article 3 of this document for details.
Co-payment
Physician Visits
Adult Immunizations. Refer 7.29. Immunizations for a complete list of Adult Immunizations.
$15.00
Annual Routine Physical
1 visit per member per plan year limited to $1500 per Member per Plan Year
$15.00
Chiropractic & Osteopathic
Includes all spinal manipulation or treatment. Limited to 20 visits per Member per Plan year (combined in-network and out-of-network) subject to being Medically Appropriate.
$15.00
Hearing Exam
One per Member per Plan Year
$15.00
Obstetrics & Gynecology OB/GYN
$10.00
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Co-payment
Physician Visits (one co-pay per day per provider)
(General Practice, Family Practice and Internal Medicine, Chiropractor, Speech Therapy*, Occupational Therapy*, Cardiac Therapy*, Respiratory Therapy*, and Physical therapy*, and Pediatrician ) *Subject to the benefit limitations described under Short-term Rehabilitative Therapy section 7.52.
Specialists Visit
$15.00
$30.00
Prenatal Care and Program
For initial diagnosis; covered at 100% thereafter
$10.00
Rehabilitation Services, Short-Term, limited to 60 visits per Member per Plan Year for all therapy types listed combined. Additional visits subject to medical necessity with Pre-Certification. Includes: Physical therapy, Occupational therapy, Speech therapy, Respiratory therapy, and Cardiac therapy.
$15.00
Urgent Care Center
$40.00
Well-Child through 23 months. (Co-pay is waived if the only service rendered is a well-child immunization).
Age 2 and over: 1 visit per Member per Plan Year (includes laboratory and radiology).
$15.00
Well-Man Care (OV, PSA Blood test). 1 visit per Member per Plan Year (includes laboratory and radiology).
$15.00
Well-Woman Exam (OV, PAP). 1 visit per Member per Plan Year (includes laboratory and radiology). *Copayment is subject to the type of provider at visit.
$15.00 PCP*
$10.00 OB-GYN*
clarification purposes without prior notice.
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Co-payment
Hospital Services
Ambulance (for medical emergency or required interfacility transport)
No charge
Hospice Care
Inpatient facility or home hospice for life expectancy of 6 months or less.
No charge
Hospital Admission
*Hospital in-patient admission co-payment: would apply to any in-patient hospital admission with or without an authorization excluding: Subacute Care, Post-Acute Care, and Hospice. Subacute Care would include but not be limited to: long-term care, hospital-based skilled nursing facilities (SNFs), and free standing SNFs.
$150.00*
Hospital Emergency Room (In-network and out-of network). Must be a Medical Emergency as defined by the Plan. *waived if admitted to hospital directly from emergency room but subject to hospital admission co-payment.
$125.00*
Intensive Care Unit
No charge
Maternity Admission
*Reimbursed if patient completes the “Healthy Pregnancy” program (must enroll by the 12th week of pregnancy and complete the program).
$250.00* per baby
Non-emergency ambulance transportation with Pre-Certification.
No charge
Private rooms when medically necessary
No charge
Radiology and Laboratory
No charge
Semi-Private Room & Board. The Plan allows charges up to 90% of the Private room rate if the facility has no Semi-Private rooms.
No charge
Skilled Nursing Facility/Rehabilitation
Hospital or sub-acute facilities.
90-day limit per Member per Plan Year.
No charge
clarification purposes without prior notice.
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Co-payment
Surgery/Anesthesia/Asst Surgeon (inpatient)
No charge
Mental Health Services
Mental/Nervous, and Substance Abuse Office Visit
$15.00
Mental/Nervous, and Substance Abuse (inpatient & residential)
$150.00
Other Services
Allergy Testing
$30.00
Antigen Administration
Desensitization/treatment
$30.00
Autism Spectrum Disorder Services
Behavioral therapy services limited to the following plan year maximum
a.
For ages 0-8 $50,000
b.
For ages 9-16 $25,000
$15.00
Bariatric Surgery
20% coinsurance
Contraceptive Appliances obtained at a Physician’s office.
$15.00
Corrective Appliances, Prosthetics, Medically Appropriate foot orthotics.
Foot orthotics limited to diabetic treatment.
No charge
Diagnostic Testing, including Laboratory and Radiology
No charge
Durable Medical Equipment (DME)
Medically Necessary.
No charge
Family Planning Services
Voluntary Tubal ligation (outpatient facility)
Vasectomy (physician’s office)
Implantable contraceptive products (limited to one per every five years)
$50.00
$30.00
$30.00
clarification purposes without prior notice.
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Co-payment
Hearing Aids
Limited to $1,500 for each ear per Member per Plan Year.
No charge
Home Health/Home Infusion Care.
Limited to 42 visits per member per Plan Year as described in section 7.27. Home Health Services.
No charge
Mammography screening
Age 35-39 one baseline
Age 40 and older annually
Non-routine services covered more frequently based on recommendation of the Member’s Physician.
No charge
Medical Foods/Metabolic Supplements and Gastric Disorder Formula. Limited to 75% to $20,000 max per Member per Plan Year.
25% coinsurance
up to $1,000 per individual or $2,000 per family Out-of-Pocket Maximum per plan year.
Organ and Tissue Transplantation and Donor Coverage. No coverage if Member is an organ donor for a recipient other than a Member enrolled under this Plan. Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor.
No charge
Ostomy supplies
No charge
Surgery Facility and Associated Physician fees
In primary physician’s office
In a specialist office
In Freestanding ambulatory facility
In hospital outpatient surgical center
$15.00
$30.00
$50.00
$50.00
clarification purposes without prior notice.
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Co-payment
PRESCRIPTION MEDICATION AND DIABETIC SUPPLIES AS IDENTIFIED UNDER ARTICLE 8.
Diabetic Supplies includes insulin, lancets, insulin syringes/needles, pre-filled cartridges, urine test strips, blood glucose testing machines, blood sugar test strips, and alcohol swabs.
Available through Mail Order and retail.
Smoking cessation aids both prescribed and over-the counter will be covered at a maximum of $500 per member per lifetime. All co-pays based on the formulary will apply. Member must have a prescription and present to an in-network pharmacy for the aid to be covered. Only FDA approved aids will be covered.
$500 maximum per lifetime
Retail Pharmacy (30-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$10.00
$20.00
$40.00
Mail Order (90-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$20.00
$40.00
$80.00
Retail (90-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$25.00
$50.00
$100.00
7.2.
DETERMINATION OF ELIGIBLE EXPENSES
Subject to the exclusions, conditions, and limitations stated in this document, the Plan will pay Benefits to, or on behalf of, a Member for covered Medical Expenses described in this section, up to the amounts stated in the Schedule of Benefits.
The Plan will pay Benefits for the Reasonable and Customary Charges or the contracted fee as determined by the Provider’s contract with the Network for services and supplies which are ordered by a Physician. clarification purposes without prior notice.
Services and supplies must be furnished by an Eligible Provider and be Medically Necessary.
The obligation of the Plan shall be fully satisfied by the payment of allowable expenses in accordance with the Schedule of Benefits. Benefits will be paid for the reimbursement of medical expenses incurred by the Member if all provisions mentioned in this document are satisfied.
All payments made under this Plan for allowable charges will be limited to Reasonable and Customary Charges or the contracted fee as determined by the Provider’s contract with the Network minus all co-pays and coinsurance stated in the Schedule of Benefits.
7.3.
Out-of-Pocket Maximum
Out-of-Pocket Expenses are Covered Expenses incurred for charges made by a Provider for which no payment is made on a portion of the claim because of the coinsurance factor for metabolic supplements.
The following do not apply to the accumulation of the maximum out-of-pocket:
1.
Prescription co-pays;
2.
All flat dollar medical co-pays such as, office visit, urgent care, emergency room, and rehabilitation therapy;
3.
Charges in excess of Reasonable and Customary; and
4.
All charges associated with a non-covered service.
When a Member has incurred Out-of-Pocket Expenses of $1,000 in a Plan Year, benefits for Covered Expenses normally payable at 75% and incurred during the rest of that Plan Year will be payable at the rate of 100% not to exceed any stated Plan maximum.
When two or more Members enrolled under a policy have incurred a combined amount of Out-of-Pocket Expenses of $2,000 in a Plan Year, benefits for you and all of your Dependents for Covered Expenses normally payable at 75% and incurred during the rest of that Plan Year will be payable at the rate of 100% not to exceed any stated Plan maximum.
All co-pays noted that are not a percentage coinsurance will continue to apply regardless of the Maximum Out-of-Pocket amount.
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7.4.
Notification, Proof of a Claim, and Payment
Inpatient hospitalization for any Emergency Services or Urgent Care requires notification to and Pre-Certification by the Medical Management Organization.
Notification of inpatient hospitalization is required as soon as reasonably possible, but no later than the second business day after admission. This requirement shall not cause denial of an otherwise valid claim if you could not reasonably comply, provided that notification is given to the Medical Management Organization as soon as reasonably possible.
Coverage for Emergency Services and Urgent Care received through non-Participating Providers shall be limited to covered services to which you would have been entitled under the Plan, and shall be reimbursed at the prevailing Reasonable and Customary rate for self-pay patients in the area where the services were provided.
Claims and supporting documentation submitted for reimbursement must meet the Timely Filing requirements and be received within one (1) year from the date the services were rendered. Claim forms are available on the Third Party Administrator website or by calling the Customer Service Center.
Foreign Claims: Request for reimbursement of foreign claims must include the following information: Employee name, member identification number, patient name, date of service, provider name and address, detailed description of the services rendered, charges, and the currency in which the charges are being reported. Foreign travel guidelines are available on the Third Party Administrator website.
7.5.
Covered Expenses
The term Covered Expenses means the expenses incurred by or on behalf of a person, if they are incurred after he becomes insured for these benefits and prior to the date coverage ends. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of a non-Occupational Injury or a Sickness.
The Covered Expenses available to a Member under this plan are described below. Any applicable Co-payments and other limits are identified in the Schedule of Benefits. Unless otherwise authorized in writing by the Plan, Covered Expenses are available to Member/Participants only if:
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1.
They are Medically Appropriate and not specifically excluded in this Article or any other Article; and
2.
Pre-Certification is obtained from the Plan by the member or provider, for those services that require Pre-Certification. To obtain Pre-Certification call the number on your ID card.
All non-emergency services within the network Service Area must be incurred at a Participating Provider. All non-emergency services outside of the network Service Area must be incurred at a Travel Network Participating Provider.
If a Member uses Participating Providers for facility and physician services for a given procedure, any assistant surgeon, anesthesiologist, radiologist, and pathologist charges in connection with that procedure will be payable at the in-network level of benefits even if rendered by non-Participating Providers. During an inpatient admission, if a consultation is required by a specialist on call at the facility causing the member to have no control over the provider chosen, charges in connection with the consult will be payable at the in-network level of benefits even if rendered by non-Participating Providers. Covered charges will be reimbursed at in-network benefit levels subject to Reasonable and Customary rates.
7.6.
Autism Spectrum Disorder Services
Behavioral therapy is only covered for the treatment of Autism spectrum Disorder as defined in Article 16. The following services are excluded Sensory Integration, LOVAAS Therapy and Music Therapy. All services are subject to the following plan year maximums:
a.
For ages 0-8 $50,000
b.
For ages 9-16 $25,000
If multiple services are provided on the same day by different Providers, a separate Co-payment will apply to each Provider.
7.7.
Physician Services
Physician Services are diagnostic and treatment services provided by Participating Physicians and Other Participating Health Professionals, including office visits, periodic health assessments, well-child care and routine immunizations provided in accordance with accepted medical practices, hospital care, consultation, and surgical procedures.
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7.8.
Inpatient Hospital Services
Inpatient hospital services are services provided for evaluation or treatment of conditions that cannot be adequately treated on an ambulatory basis or in another Participating Health Care Facility. Inpatient hospital services include semi-private room and board; care and services in an intensive care unit; drugs, medications, biologicals, fluids, blood and blood products, and chemotherapy; special diets; dressings and casts; general nursing care; use of operating room and related facilities; laboratory and radiology services and other diagnostic and therapeutic services; anesthesia and associated services; inhalation therapy; radiation therapy; admit kit; and other services which are customarily provided in acute care hospitals. Inpatient hospital services also include Birthing Centers.
7.9.
Outpatient Facility Services
Outpatient facility services are services provided on an outpatient basis, including: diagnostic and/or treatment services; administered drugs, medications, fluids, biologicals, blood and blood products; inhalation therapy; and procedures which can be appropriately provided on an outpatient basis, including certain surgical procedures, anesthesia, and recovery room services.
7.10.
Emergency Services and Urgent Care
In the event of an emergency, get help immediately. Go to the nearest emergency room, the nearest hospital or call or ask someone to call 911 or your local emergency service, police or fire department for help. You do not need a referral from your Physician for Emergency Services, but you should call your Physician as soon as possible for further assistance and advice on follow-up care. If you require specialty care or a hospital admission, contact the Medical Management Organization to obtain necessary authorizations for care or hospitalization.
If you receive Emergency Services outside the Service Area, you must notify the Third Party Claim Administrator as soon as reasonably possible. We may arrange to have you transferred to a Participating Provider for continuing or follow-up care if it is determined to be medically safe to do so.
“Emergency Services” are defined as a medical or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the insured person in serious jeopardy, serious impairment to bodily
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functions, serious disfigurement of the insured person, serious impairment of any bodily organ or part of the insured person, or in the case of a behavioral condition, placing the health of the insured person or other persons in serious jeopardy.
Examples of emergency situations include uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, burns, cuts, and broken bones. The symptoms that led you to believe you needed emergency care, as coded by the provider and recorded by the hospital on the UB92 claim form or its successor, or the final diagnosis, whichever reasonably indicated an emergency medical condition, will be the basis for the determination of coverage, provided such symptoms reasonably indicate an emergency. You are covered for at least a screening examination to determine whether an emergency exists. Care up and through stabilization for an emergency situation is covered without prior authorization.
For Urgent Care services, you should take all reasonable steps to contact your Physician for direction and you must receive care from a Participating Provider, unless otherwise authorized by the Plan. If you are traveling outside of the network’s service area in which you are enrolled, you should, whenever possible, contact the Plan or your Physician for direction and authorization prior to receiving services.
“Urgent Care” is defined as medical, surgical, hospital and related health care services and testing which are not Emergency Services, but which are determined by the Plan in accordance with generally accepted medical standards to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or are scheduled to receive services. Such care includes but is not limited to: dialysis, scheduled medical treatments or therapy, or care received after a Physician’s recommendation that you should not travel due to any medical condition.
7.11.
Continuing or Follow-up Treatment
Continuing or follow-up treatment by providers out of the Service Area is not covered unless it is Pre-Certified by the Medical Management Organization.
38 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
7.12.
Ambulance Service
Ambulance services to/from an appropriate provider or facility are covered for emergencies. Pre-Certification for non-emergency ambulance services may be obtained from the Medical Management Organization by a provider that is treating the Member.
Covered Expenses include charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.
7.13.
Bariatric Surgery
The plan covers the following bariatric surgery procedures: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if all the following criteria are met:
1. The patient must have a body-mass index (BMI) ≥35.
2. Have at least one co-morbidity related to obesity
3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record:
Active participation within the last two years in one physician –supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must included monthly documentation of all of the following components:
a. Weight
b. Current dietary program
c. Physical activity (e.g., exercise program)
4. In addition, the procedure must be performed at an approved facility that is credentialed by your Health Network to perform bariatric surgery.
5. The member must be 18 years or older, or have reached full expected skeletal growth.
If treatment was directly paid or covered by another plan medically necessary adjustments will be covered.
The following bariatric procedures are excluded:
1. Open vertical banded gastroplasty.
2. Laparoscopic vertical banded gastroplasty.
3. Open sleeve gastrectomy.
39 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
4. Laparoscopic sleeve gastrectomy.
5. Open adjustable gastric banding.
7.14.
Breast Reconstruction and Breast Prostheses
Following a mastectomy, the following services and supplies are covered:
1.
Surgical services for reconstruction of the breast on which the mastectomy was performed;
2.
Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;
3.
Post-operative breast prostheses; and
4.
Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.
During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered.
7.15.
Cancer Clinical Trials
Coverage shall be provided for Medically Appropriate covered patient costs that are directly associated with a cancer clinical trial that is offered in the State of Arizona and in which the Member participates voluntarily. A cancer clinical trial is a course of treatment in which all of the following apply:
1.
The treatment is part of a scientific study of a new therapy or intervention that is being conducted at an institution in the State of Arizona, that is for the treatment, palliation or prevention of cancer in humans and in which the scientific study includes all of the following: (a) specific goals; (b) a rationale and background for the study; (c) criteria for patient selection; (d) specific directions for administering the therapy and monitoring patients; (e) definition of quantitative measures for determining treatment response; and (f) methods for documenting and treating adverse reactions;
2.
The treatment is being provided as part of a study being conducted in a phase I, phase II, phase III or phase 4 cancer clinical trial;
3.
The treatment is being provided as part of a study being conducted in accordance with a clinical trial approved by at least one of the following: (a) One of the National Institutes of Health; (b) A National Institutes of Health Cooperative Group or Center; (c) The United States Food and Drug Administration in the form of an investigational new drug application;(d) The United States 40 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
Department of Defense; (e) The United States Department of Veteran Affairs; (f) a qualified research entity that meets the criteria established by the National Institutes of Health for grant eligibility; or (g) a panel of qualified recognized experts in clinical research within academic health institutions in the State of Arizona;
4.
The proposed treatment or study has been reviewed and approved by an institutional review board of an institution in the State of Arizona;
5.
The personnel providing the treatment or conducting the study (a) are providing the treatment or conducting the study within their scope of practice, experience and training and are capable of providing the treatment because of their experience, training and volume of patients treated to maintain expertise;(b) agree to accept reimbursement as payment in full from the Plan at the rates that are established by the Plan and that are not more than the level of reimbursement applicable to other similar services provided by the health care providers with the Plan’s network;
6.
There is no clearly superior, non-investigational treatment alternative;
7.
The available clinical or pre-clinical data provide a reasonable expectation that the treatment will be at least as efficacious as any non-investigational alternative;
For the purposes of this specific covered service and benefit, coverage outside the State of Arizona will be provided under the following conditions:
(a) The clinical trial treatment is curative in nature; (b) The treatment is not available through a clinical trial in the State of Arizona; (c) There is no other non-investigational treatment alternative;
For the purposes of this specific covered service and benefit, the following definitions apply:
1.
“Cooperative Group” – means a formal network of facilities that collaborates on research projects and that has an established national institutes of health approved peer review program operating within the group, including the National Cancer Institute Clinical Cooperative Group and The National Cancer Institute Community Clinical Oncology Program.
2.
“Institutional Review Board” – means any board, committee or other group that is both: (a) formally designated by an institution to approve the initiation of and to conduct periodic review of biomedical research involving human subjects and in which the primary purpose of such review is to assure the protection of the 41 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
rights and welfare of the human subjects and not to review a clinical trial for scientific merit; and (b) approved by the National Institutes of Health Office for Protection From Research Risks.
3.
“Multiple Project Assurance Contract” – means a contract between an institution and the United States Department of Health and Human Services that defines the relationship of the institution to the United States Department of Health and Human Services and that sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.
4.
“Patient Cost” – means any fee or expense that is covered under the Plan and that is for a service or treatment that would be required if the patient were receiving usual and customary care.
Patient cost does not include the cost: (a) of any drug or device provided in a phase I cancer clinical trial; (b) of any investigational drug or device; (c) of non-health services that might be required for a person to receive treatment or intervention; (d) of managing the research of the clinical trial; (e) that would not be covered under the Plan; and (f) of treatment or services provided outside the State of Arizona.
7.16.
Chiropractic Care Services
Chiropractic care services include diagnostic and treatment services utilized in an office setting by Participating chiropractic Physicians and Osteopaths. Chiropractic treatment includes the conservative management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain and improve function.
The following are specifically excluded from chiropractic care and osteopathic services:
1.
Services of a chiropractor or osteopath which are not within his scope of practice, as defined by state law;
2.
Charges for care not provided in an office setting;
3.
Maintenance or preventive treatment consisting of routine, long term or non-Medically Appropriate care provided to prevent reoccurrences or to maintain the patient’s current status; and
4.
Vitamin therapy.
Services are limited to twenty (20) visits per Member per Plan year.
42 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
7.17.
Cosmetic Surgery
Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.
7.18.
Dental Confinements/Anesthesia
Facility and anesthesia services for hospitalization in connection with dental or oral surgery will be covered, provided that the confinement has been Pre-Authorized because of a hazardous medical condition. Such conditions include heart problems, diabetes, hemophilia, dental extractions due to cancer related conditions, and the probability of allergic reaction (or any other condition that could increase the danger of anesthesia). All facility services must be provided by a contracted network provider.
7.19.
Dental Services – Accident only
Dental services are covered for the treatment of a fractured jaw or an Injury to sound natural teeth. Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an Accidental Injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.
Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support, and are functional in the arch.
7.20.
Diabetic Service and Supplies
Coverage will be provided for the following Medically Appropriate supplies, devices, and appliances prescribed by a health care provider for the treatment of diabetes:
1.
Podiatric/ appliances for prevention of complications associated with diabetes; foot orthotic devices and inserts (therapeutic shoes: including Depth shoes or Custom Molded shoes.) Custom molded shoes will only be covered when the member has a foot deformity that cannot be accommodated by a depth shoe. Therapeutic shoes are covered only for diabetes mellitus and any of the following complications involving the foot: Peripheral neuropathy with evidence of callus formation; or history of pre-ulcerative calluses; or history of previous ulceration; or foot deformity; or previous amputation of the foot or part of the foot; 43 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
or poor circulation. Definitions of Depth shoes and custom molded shoes are as follows:
⎯
Depth Shoes shall mean the shoe has a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16th inch of additional depth used to accommodate custom-molded or customized inserts; are made of leather or other suitable material of equal quality; have some sort of shoe closure; and are available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard sizing schedule or its equivalent.
⎯
Custom-molded shoes shall mean constructed over a positive model of the member’s foot; made from leather or other suitable material of equal quality; have removable inserts that can be altered or replaced as the member’s condition warrants; and have some sort of shoe closure. This includes a shoe with or without an internally seamless toe.
2.
Any other device, medication, equipment or supply for which coverage is required under Medicare guidelines pertaining to diabetes management; and
3.
Charges for training by a Physician, including a podiatrist with recent education in diabetes management, but limited to the following:
a.
Medically Appropriate visits when diabetes is diagnosed;
b.
Visits following a diagnosis of a significant change in the symptoms or conditions that warrant change in self-management;
c.
Visits when reeducation or refresher training is prescribed by the Physician; and
d.
Medical nutrition therapy (education) related to diabetes management.
7.21.
Diagnostic testing, including Laboratory and Radiology Services
Diagnostic testing includes radiological procedures, laboratory tests, and other diagnostic procedures.
7.22.
Durable Medical Equipment
44 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
Purchase or rental of durable medical equipment is covered when ordered or prescribed by a Participating Physician and provided by a vendor approved by the Plan. The determination to either purchase or rent equipment will be made by the Medical Management Organization. Coverage for repair, replacement or duplicate equipment is not covered clarification purposes without prior notice.
except when replacement or revision is necessary due to anatomical growth or a change in medical condition.
Durable medical equipment is defined as:
1.
Generally for the medical or surgical treatment of an Illness or Injury, as certified in writing by the attending medical provider;
2.
Serves a therapeutic purpose with respect to a particular Illness or Injury under treatment in accordance with accepted medical practice;
3.
Items which are designed for and able to withstand repeated use by more than one person;
4.
Is of a truly durable nature;
5.
Appropriate for use in the home; and
6.
Is not useful in the absence of Illness or Injury.
Such equipment includes, but is not limited to, crutches, hospital beds (to maximum of $5,000 annually), wheel chairs, respirators, and dialysis machines.
Unless covered in connection with the services described in the "Inpatient Services at Other Participating Health Care Facilities" or "Home Health Services" provisions, the following are specifically excluded:
1.
Hygienic or self-help items or equipment;
2.
Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment;
3.
Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines;
4.
Institutional equipment, such as air fluidized beds and diathermy machines;
5.
Elastic stockings and wigs;
6.
Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, foot orthotics, braces and splints;
7.
Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; and
8.
Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars.
9.
Hearing aid batteries (except those for cochlear implants) and chargers.
45 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
7.23.
External Prosthetic Appliances
The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury or congenital defect. External prosthetic appliances shall include artificial arms and legs, hearing aids and terminal devices such as a hand or hook. Replacement of external prosthetic appliances (except for hearing aids) is covered only if necessitated by normal anatomical growth or as a result of wear and tear.
The following are specifically excluded:
1.
Any biomechanical devices. Biomechanical devices are any external prosthetics operated through or in conjunction with nerve conduction or other electrical impulses;
2.
Replacement of external prosthetic appliances due to loss or theft; and
3.
Wigs or hairpieces.
7.24.
Family Planning Services (Contraception and Voluntary Sterilization)
Covered family planning services including:
1.
Medical history;
2.
Physical examination;
3.
Related laboratory tests;
4.
Medical supervision in accordance with generally accepted medical practice;
5.
Information and counseling on contraception;
6.
Implanted/injected contraceptives; and
7.
After appropriate counseling, Medical Services connected with surgical therapies (vasectomy or tubal ligation).
7.25.
Foot Orthotics
The following foot orthotics are covered by the plan for treatment of diabetes see 7.20. Diabetic Services and Supplies:
Custom-molded shoes constructed over a positive model of the member’s foot made from leather or other suitable material of equal quality containing removable inserts that can be altered or replaced as the member’s condition warrants and have some sort of shoe closure. This includes a shoe with or without an internally seamless toe.
46 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
7.26.
Hearing Aids
Hearing aid services limited to $1,500 for each ear per Member, per Plan Year. The following services are covered:
•
New or replacement hearing aids no longer under warranty (pre-certification required).
•
Cleaning or repair
•
Batteries for cochlear implants
7.27.
Home Health Services
Home health services limited to a maximum of 42 visits per member per plan year are covered when the following criteria are met:
1.
The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.
2.
The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.
3.
The patient must be homebound.
4.
The home health agency delivering care must be certified within the state the care is received.
5.
The care that is being provided is not custodial care.
A Home Health visit is considered to be up to four hours of services. Home health services do not include services of a person who is a member of your family or your dependent’s family or who normally resides in your house or your dependent’s house. Physical, occupational, and speech therapy provided in the home are also subject to the 60 visit benefit limitations described under 7.52. Short-Term Rehabilitative Therapy.
7.28.
Hospice Services
The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. Hospice care services include inpatient care; outpatient services; professional services of a Physician; services of a psychologist, social worker or family counselor for individual and family counseling; and home health services.
Hospice care services do not include the following:
1.
Services of a person who is a member of your family or your dependent's family or who normally resides in your house or your dependent's house;
47 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
2.
Services and supplies for curative or life prolonging procedures;
3.
Services and supplies for which any other benefits are payable under the Plan;
4.
Services and supplies that are primarily to aid you or your dependent in daily living;
5.
Services and supplies for respite (custodial) care; and
6.
Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals.
Hospice care services are services provided by a Participating Hospital; a Participating skilled nursing facility or a similar institution; a Participating home health care agency; a Participating hospice facility, or any other licensed facility or agency under a Medicare approved hospice care program.
A hospice care program is a coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and their families; a program that provides palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness; and a program for persons who have a terminal illness and for the families of those persons.
A hospice facility is a Participating institution or portion of a facility which primarily provides care for terminally ill patients; is a Medicare approved hospice care facility; meets standards established by the Plan; and fulfills all licensing requirements of the state or locality in which it operates.
7.29.
Immunizations
Immunizations are not subject to the annual routine maximum benefit.
Covered immunizations for adults and children over age 2 include:
1.
Influenza, Trivalent inactivated influenza vaccine (TIV)
2.
Influenza, Live attenuated influenza vaccine (LAIV)
3.
Pneumococcal
4.
Hepatitis B (Hep B)
5.
Hepatitis A (Hep A)
6.
Td (Tetanus, diphtheria)
7.
Polio (IPV)
8.
Varicella (Var)
9.
Meningococcal Conjugate vaccine (MCV4)
10.
MMR (Measles, mumps, rubella)
11.
HPV Vaccine, Gardasil
12.
Shingles Vaccine, Zoster
48 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
13.
Other immunizations approved by the plan.
7.30.
Inpatient Services at Other Participating Health Care Facilities
Inpatient services include semi-private room and board; skilled and general nursing services; Physician visits; physiotherapy; speech therapy; occupational therapy; x-rays; and administration of drugs, medications, biologicals and fluids.
7.31.
Insulin Pumps and Supplies
Insulin pumps and insulin pump supplies are covered when ordered by a Physician and obtained through a contracted durable medical equipment supplier. You may call the Customer Service number on your ID card if you need assistance locating a contracted supplier.
7.32.
Internal Prosthetic/Medical Appliances
Internal prosthetic/medical appliances are prosthetics and appliances that are permanent or temporary internal aids and supports for non-functional body parts, including testicular implants following Medically Appropriate surgical removal of the testicles. Medically Appropriate repair, maintenance or replacement of a covered appliance is covered.
7.33.
Mammograms
Mammograms are covered for routine and diagnostic breast cancer screening as follows:
1.
A single baseline mammogram if you are age 35-39;
2.
Once per Plan Year if you are age 40 and older.
7.34.
Maternity Care Services
Maternity care services include medical, surgical and hospital care during the term of pregnancy, upon delivery and during the postpartum period for normal delivery, cesarean section, spontaneous abortion (miscarriage), complications of pregnancy, and maternal risk. Inpatient maternity delivery is subject to a $250.00 maternity delivery co-payment per child. The $250.00 co-payment will be reimbursed if the member enrolls in the health pregnancy program prior to the 12th week of pregnancy and completes the program.
Coverage for a mother and her newly born child shall be available for a minimum of forty-eight (48) hours of inpatient care following a vaginal delivery and a minimum of ninety-six (96) hours of inpatient care following a cesarean section. Any decision to shorten the period of
49 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
inpatient care for the mother or the newborn must be made by the attending Physician in consultation with the mother.
These maternity care benefits also apply to the natural mother of a newborn child legally adopted by you in accordance with the Plan adoption policies.
These benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.
Charges incurred at the birth for the delivery of a child only to the extent that they exceed the birth mother’s coverage, if any, provided:
1.
That child is legally adopted by you within one year from date of birth;
2.
You are legally obligated to pay the cost of the birth;
3.
You notify the Plan of the adoption within 60 days after approval of the adoption or a change in the insurance policies, plans or company; and
4.
You choose to file a claim for such expenses subject to all other terms of these medical benefits.
7.35.
Medical Foods / Metabolic Supplements and Gastric Disorder Formula
Medical foods, metabolic supplements and Gastric Disorder Formula to treat inherited metabolic disorders or a permanent disease/non-functioning condition in which a Member is unable to sustain weight and strength commensurate with the Member’s overall health status are covered.
Inherited metabolic disorders triggering medical food coverage are:
1.
Part of the newborn screening program as prescribed by Arizona statute; involve amino acid, carbohydrate or fat metabolism;
2.
Have medically standard methods of diagnosis, treatment and monitoring including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues; and
3.
Require specifically processed or treated medical foods that are generally available only under the supervision and direction of a physician, that must be consumed throughout life and without which the person may suffer serious mental or physical impairment.
50 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
For non-inherited disorders, enteral nutrition is considered Medically Appropriate when the Member has:
1.
A permanent non-function or disease of the structures that normally permit food to reach the small bowel; or
2.
A disease of the small bowel which impairs digestion and absorption of an oral diet consisting of solid or semi-solid foods.
The Plan will cover up to 75% of the cost of medical foods prescribed to treat metabolic disorders covered under this Plan. There is a maximum Plan Year limit for medical foods of $20,000 which applies to the cost of all prescribed modified low protein foods and metabolic formula.
For the purpose of this section, the following definitions apply:
“Inherited Metabolic Disorder” means a disease caused by an inherited abnormality of body chemistry and includes a disease tested under the newborn screening program as prescribed by Arizona statute. Medical Foods means modified low protein foods and metabolic formula.
“Metabolic Formula” means foods that are all of the following:
1.
Formulated to be consumed or administered internally under the supervision of a medical doctor or doctor of osteopathy;
2.
Processed or formulated to be deficient in one or more of the nutrients present in typical foodstuffs;
3.
Administered for the medical and nutritional management of a person who has limited capacity to metabolize foodstuffs or certain nutrients contained in the foodstuffs or who has other specific nutrient requirements as established by medical evaluation; and
4.
Essential to a person’s optimal growth, health and metabolic homeostasis.
“Modified Low Protein Foods” means foods that are all of the following: formulated to be consumed or administered internally under the supervision of a medical doctor or doctor of osteopathy:
1.
Processed or formulated to contain less than one gram of protein per unit of serving, but does not include a natural food that is naturally low in protein;
2.
Administered for the medical and nutritional management of a person who has limited capacity to metabolize foodstuffs or certain nutrients contained in the foodstuffs or who has other 51 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
specific nutrients requirements as established by medical evaluation; and
3.
Essential to a person’s optimal growth, health and metabolic homeostasis.
The following are not considered Medically Appropriate and are not covered as a Metabolic Food / Metabolic Supplement and Gastric Disorder Formula:
1.
Standard oral infant formula;
2.
Food thickeners, baby food, or other regular grocery products;
3.
Nutrition for a diagnosis of anorexia; and
4.
Nutrition for nausea associated with mood disorder, end-stage disease, etc.
7.36.
Medical Supplies
Medical supplies include Medically Appropriate supplies which may be considered disposable, however, are required for a Member in a course of treatment for a specific medical condition. Supplies must be obtained from a Participating Provider. Over the counter supplies, such as band-aids and gauze are not covered.
7.37.
Mental Health and Substance Abuse Services
Mental Health Services are those services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to mental health will not be considered to be charges made for treatment of mental health.
Substance Abuse is defined as the psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care, and treatment. In determining benefits payable, charges made for the treatment of any conditions of physiological instability requiring medical hospitalization will not be considered to be charges made for treatment of substance abuse.
7.38.
Inpatient Mental Health Services
Inpatient Mental Health Services are services that are provided by a Participating Hospital for the treatment and evaluation of mental health during an inpatient admission.
7.39.
Outpatient Mental Health Services
Outpatient Mental Health Services are services by Participating Providers who are qualified to treat mental health when treatment is
52 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
provided on an outpatient basis in an individual, group or structured group therapy program. Covered services include, but are not limited to, outpatient treatment of conditions such as: anxiety or depression which interferes with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; neuropsychological testing; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic mental health conditions (crisis intervention and relapse prevention), outpatient testing/assessment, and medication management when provided in conjunction with a consultation.
7.40.
Outpatient Substance Abuse Rehabilitation Services
Outpatient substance abuse services include services for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs including outpatient rehabilitation in an individual, group, structured group or intensive outpatient structured therapy program. Intensive outpatient structured therapy programs consist of distinct levels or phases of treatment that are provided by a certified/licensed substance abuse program. Intensive outpatient structured therapy programs provide nine or more hours of individual, family and/or group therapy in a week.
7.41.
Residential Substance Abuse Treatment
Voluntary and court-ordered residential substance abuse treatment will be covered for a maximum of 90 days and limited to two treatments per plan year for chemical and alcohol dependency.
7.42.
Substance Abuse Detoxification Services
Substance abuse detoxification services include detoxification and related medical ancillary services when required for the diagnosis and treatment of addiction to alcohol and/or drugs, and medication management when provided in conjunction with a consultation. The Medical Management Organization will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting. In-patient detoxification coverage is limited to two treatments per year and a lifetime maximum of five.
7.43.
Excluded Mental Health and Substance Abuse Services
The following are specifically excluded from mental health and substance abuse services:
1.
Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody 53 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan;
2.
Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain;
3.
Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice;
4.
Developmental disorders, including but not limited to:
a.
developmental reading disorders;
b.
developmental arithmetic disorders;
c.
developmental language disorders; or
d.
articulation disorders.
5.
Counseling for activities of an educational nature;
6.
Counseling for borderline intellectual functioning;
7.
Counseling for occupational problems;
8.
Counseling related to consciousness raising;
9.
Vocational or religious counseling;
10.
I.Q. testing;
11.
Residential treatment; (unless associated with chemical or alcohol dependency as described in the Residential Substance Abuse Treatment provisions)
12.
Marriage counseling;
13.
Custodial care, including but not limited to geriatric day care;
14.
Psychological testing on children requested by or for a school system; and
15.
Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline.
16.
Biofeedback is not covered for reasons other than pain management.
7.44.
Nutritional Evaluation
Nutritional evaluation and counseling from a Participating Provider is covered when diet is a part of the medical management of a documented organic disease, including morbid obesity.
All other services for the purpose of diet control and weight reduction are not covered unless required by a specifically identified condition of disease etiology. Services not covered include but not limited to: gastric surgery, intra oral wiring, gastric balloons, dietary formulae, hypnosis, cosmetics, and health and beauty aids.
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7.45.
Obstetrical and Gynecological Services
Obstetrical and gynecological services are covered when provided by qualified Participating Providers for pregnancy, well-women gynecological exams, primary and preventive gynecological care and acute gynecological conditions.
7.46.
Organ Transplant Services
Human organ and tissue transplant services are covered at designated facilities throughout the United States. This coverage is subject to the following conditions and limitations. Due to the specialized medical care required for transplants, the Provider Network for this specific service may not be the same as the medical network in which you enrolled.
These benefits are only available when the Member is the recipient of an organ transplant. No benefits are available where the Member is an organ donor for a recipient other than a Member enrolled on the same family policy.
Organ transplant services include the recipient’s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:
1.
Allogeneic bone marrow/stem cell;
2.
Autologous bone marrow/stem cell;
3.
Cornea;
4.
Heart;
5.
Heart/lung;
6.
Kidney;
7.
Kidney/pancreas;
8.
Liver;
9.
Lung;
10.
Pancreas; or
11.
Small bowel/liver
12.
Kidney/liver
Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. All organ transplant services other than cornea, kidney and autologous bone marrow/stem cell transplants must be received at a qualified organ transplant facility.
Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ
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removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
7.47.
Organ Transplant Travel Services
Travel expenses incurred by the Member in connection with a pre-approved organ/tissue transplant are covered subject to the following conditions and limitations. Travel expenses are limited to $10,000. Organ transplant travel benefits are not available for cornea transplants. Benefits for transportation, lodging and food are available only for the recipient of a pre-approved organ/tissue transplant from a transplant facility. The term recipient is defined to include a Member receiving authorized transplant related services during any of the following:
1.
Evaluation,
2.
Candidacy,
3.
Transplant event, or
4.
Post-transplant care.
All claims filed for travel expenses must include detailed receipts, except for mileage. Transportation mileage will be calculated by the Third Party Claim Administrator based on the home address of the Member and the transplant site. Travel expenses for the Member receiving the transplant will include charges for:
1.
Transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility);
2.
Transportation to and from the transplant site in a personal vehicle will be reimbursed at 37.5 cents per mile when the transplant site is more than 60 miles one way from the Member’s home.
3.
Lodging while at, or traveling to and from the transplant site;
4.
Food while at, or traveling to and from the transplant site.
In addition to the Member being covered for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany the Member. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver.
The following are specifically excluded travel expenses:
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clarification purposes without prior notice.
1.
Travel costs incurred due to travel within 60 miles of your home;
2.
Laundry bills;
3.
Telephone bills;
4.
Alcohol or tobacco products; and
5.
Charges for transportation that exceed coach class rates.
7.48.
Ostomy Supplies
Ostomy supplies are supplies which are medically appropriate for care and cleaning of a temporary or permanent ostomy. Covered supplies include, but are not limited to pouches, face plates and belts, irrigation sleeves, bags and catheters, skin barriers, gauze, adhesive, adhesive remover, deodorant, pouch covers, and other supplies as appropriate.
7.49.
Oxygen and the Oxygen Delivery System.
Coverage of oxygen that is routinely used on an outpatient basis is limited to coverage within the Service Area. Oxygen Services and Supplies are not covered outside of the Service Area, except on an emergency basis.
7.50.
Periodic Routine Health Examinations
Well Child visits and immunizations are covered through 23 months as recommended by the American Academy of Pediatrics.
Well woman exams are covered in addition to periodic health exams. Covered expenses include an annual office visit and one Papanicolaou test (PAP smear). Laboratory charges are covered as a separate expense. Limited to 1 visit per Member per Plan Year.
Well man exams are covered in addition to periodic health exams. Covered expenses include an annual office visit with prostate-specific antigen (PSA) test. Laboratory charges are covered as a separate expense. Limited to 1 visit per Member per Plan Year.
Periodic routine health examinations age 2 and over by a physician limited to one (1) visit per Member per Plan Year and $1500 maximum benefit paid per Member per Plan Year. To include laboratory, radiology services, routine vision, and hearing screening, provided by a Physician.
Well child, well woman, and well man exams do not apply to the stated periodic routine health examination limits.
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7.51.
Radiation Therapy
Radiation therapy and other therapeutic radiological procedures are covered.
7.52.
Short-term Rehabilitative Therapy
Short-term rehabilitative therapy includes services in an outpatient facility or physician’s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Covered expenses are limited to sixty (60) visits per Member per Plan Year additional visits subject to medical necessity with pre-certification.
The following limitations apply to short-term rehabilitative therapy:
1.
Occupational therapy is provided only for purposes of training Members to perform the activities of daily living.
2.
Speech therapy is not covered when:
a.
Used to improve speech skills that have not fully developed;
b.
Considered custodial or educational;
c.
Intended to maintain speech communication; or
d.
Not restorative in nature.
3.
Phase 3 cardiac rehabilitation is not covered.
If multiple services are provided on the same day by different Providers, a separate Co-payment will apply to each Provider.
7.53.
Surgical Procedures – Multiple/Bilateral
Multiple or Bilateral Surgical Procedures performed by one or more qualified physicians during the same operative session will be covered according to the following guidelines:
1.
The lesser of the actual charges, Reasonable and Customary amount, or the contracted fee as determined by the Provider’s contract with the Network will be allowed for the primary Surgical Procedure.
2.
50% of the lesser of the actual charges, Reasonable and Customary amount, or the contracted fee as determined by the Provider’s contract with the Network (not to exceed the actual charge) will be allowed for the secondary Surgical Procedure.
7.54.
Temporomandibular Joint (TMJ) Disorder
Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of:
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1.
An accident;
2.
Trauma;
3.
A congenital defect;
4.
A developmental defect; or
5.
A pathology.
Covered expenses include diagnosis and treatment of TMJ that is recognized by the medical or dental profession as effective and appropriate treatment for TMJ, including intra-oral splints that stabilize the jaw joint.
Orthognathic treatment/surgery, dental and orthodontic services and/or appliances that are orthodontic in nature or change the occlusion of the teeth (external or intra-oral) are not covered.
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ARTICLE 8
PRESCRIPTION DRUG BENEFITS
8.1.
Prescription Drug Benefit
If a Member incurs expenses for charges made by a Pharmacy for Covered Prescription Drugs, the Plan will pay a portion of the expense remaining after you have paid the required Co-payment shown in the Schedule of Benefits. The Prescription Drug Benefits are provided through the Plan Sponsor and administered by the Pharmacy Benefit Management vendor, an organization which has been contracted by the Plan Sponsor to perform these services.
The Member must pay a portion of Covered Prescription Drugs to receive Prescription Drug Benefits. That portion is described below. The Prescription Drug Co-payment is not considered an Eligible Expense under the medical portion of this Plan and do not accrue to the medical Plan Maximum Out-of-Pocket.
Dispense As Written or “DAW” are the rules associated with how the plan will pay for a name-brand prescription that has a generic equivalent. There are two rules related to this coverage “DAW1” and “DAW2”.
DAW1 – The drug is available as a generic, but the physician has requested that the brand be dispensed to the member. The member will be responsible for a generic co-pay plus the difference in cost between the brand drug and the generic drug.
DAW2 – The drug is available as a generic, but the member has requested that the brand be dispensed. The member will be responsible for a generic copay plus the difference in cost between the brand drug and the generic drug.
To avoid additional cost above the co-payment amounts members should ask their doctor to prescribe any available generic equivalent medications.
The Preferred Medication List (PML), also known as a formulary, is a list of medications that will allow you to maximize the value of your prescription benefit. These medications, chosen by a committee of doctors and pharmacists, are lower-cost generics and brand names that are available at a lower cost than their more expensive brand-name
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counterparts. The PML is updated quarterly, and as needed throughout the year to add significant new medications as they become available. Medications that no longer offer the best therapeutic value for the plan are deleted from the PML once a year, and a letter is sent to any member affected by the change. To see what medications are on the PML, log on to the PBM website or contact the Customer Service Center listed on your ID card. You may have a copy sent to you. Sharing this information with your doctor helps ensure that you are getting the medications you need, and saving money for both you and your plan.
CO-PAYMENT is that portion of Covered Prescription Drugs which you are required to pay under this benefit. In addition to the co-payments outlined below, members will be required to pay the difference in the medication cost of a generic medication versus a name-brand medication when the member requests the brand name drug and the prescribing physician has indicated the generic equivalent substitution is allowable. The plan will exclude Narrow Therapeutic Index (NTI) drugs from the co-pay penalties.
PARTICIPATING RETAIL PHARMACY CO-PAYMENT (up to a 30-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $10
For Formulary Brand-Name Drugs $20
For Non-Formulary Brand-Name Drugs $40
PARTICIPATING MAIL ORDER PHARMACY CO-PAYMENT (up to a 90-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $20
For Formulary Brand-Name Drugs $40
For Non-Formulary Brand-Name Drugs $80
PARTICIPATING RETAIL CO-PAYMENT (up to a 90-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $25
For Formulary Brand-Name Drugs $50
For Non-Formulary Brand-Name Drugs $100
No payment will be made under any other section for expenses incurred to the extent that benefits are payable for those expenses under this section.
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8.2.
Covered Prescription Drugs
The term Covered Prescription Drugs means:
1.
A Prescription Legend Drug for which a written prescription is required. A Legend Drug is one which has on its label "caution: federal law prohibits dispensing without a prescription";
2.
Insulin; pre-filled insulin cartridges for the blind; oral blood sugar control agents;
3.
Needles, syringes, glucose monitors, and machines, glucose test strips, visual reading ketone strips; urine test strips, lancets and alcohol swaps are all covered when dispensed by the mail order and retail pharmacy program;
4.
A compound medication of which at least one ingredient is a Prescription Legend Drug;
5.
Tretinoin for individuals through age 24;
6.
Any other drug which, under the applicable state law, may be dispensed only upon the written prescription of a Physician;
7.
Oral contraceptives or contraceptive devices, regardless of intended use, except that implantable contraceptive devices, such as Norplant, are not considered Covered Prescription Drugs;
8.
Prenatal vitamins, upon written prescription;
9.
Growth hormones; (with prior-authorization); or
11. Injectable drugs or medicines for which a prescription is required, except injectable infertility drugs.
8.3.
Limitations
No payment will be made for expenses incurred for the following:
1.
For non-legend drugs, other than those specified under ‘‘Covered Prescription Drugs’’;
2.
To the extent that payment is unlawful where the person resides when expenses are incurred;
3.
For charges which the person is not legally required to pay;
4.
For charges which would not have been made if the person were not covered by these benefits;
5.
For experimental drugs or for drugs labeled: ‘‘Caution limited by federal law to investigational use’’;
6.
For drugs which are not considered essential for the necessary care and treatment of a non-occupational Injury or Sickness, as determined by the Plan Administrator;
7.
For drugs obtained from a non-Participating Pharmacy;
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8.
For any prescription filled in excess of the number specified by the Physician or dispensed more than one year from the date of the Physician’s order;
9.
For more than a 30-day supply when dispensed in any one Prescription Order through a Retail Pharmacy;
10.
For more than a 90-day supply when dispensed in any one Prescription Order through a Participating Mail-Order Pharmacy;
11.
For indications not approved by the Food and Drug Administration;
12.
For immunization agents, biological sera, blood, or blood plasma;
13.
For therapeutic devices or appliances, support garments and other non-medicinal substances, excluding insulin syringes;
14.
For drugs for cosmetic purposes;
15.
For tretinoin for individuals age 25 and over;
16.
For administration of any drug;
17.
For medication which is taken or administered, in whole or in part, at the place where it is dispensed or while a person is a patient in an institution which operates, or allows to be operated on its premises, a facility for dispensing pharmaceuticals;
18.
For prescriptions which an eligible person is entitled to receive without charge from any workers’ compensation or similar law or any public program other than Medicaid;
19.
For non-Medically Appropriate anabolic steroids;
20.
For nutritional or dietary supplements, or anorexients;
21.
Implantable contraceptive devices;
22.
For prescription vitamins other than prenatal vitamins, upon
23.
written prescription;
24.
For all medications administered for the purpose of weight loss/obesity;
25.
For treatment of erectile or sexual dysfunction (both male and female); or
26.
For all injectable infertility drugs.
27.
Prescription medications that have over-the-counter (OTC) equivalents.
8.4.
Specialty Pharmacy
Certain medications used for treating chronic or complex health conditions are handled through the PBM’s Specialty Pharmacy Program.
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The purpose of the Specialty Pharmacy Program is to assist you with monitoring your medication needs for conditions such as those listed below and providing patient education. The Program includes monitoring of specific injectable drugs and other therapies requiring complex administration methods, special storage, handling, and delivery.
clarification purposes without prior notice.
Medications for these conditions through this Specialty Pharmacy Program include but are not limited to the following:
1.
Cystic Fibrosis;
2.
Multiple Sclerosis;
3.
Rheumatoid Arthritis;
4.
Prostate Cancer;
5.
Endometriosis;
6.
Enzyme replacement;
7.
Precocious puberty;
8.
Osteoarthritis;
9.
Viral Hepatitis; or
10.
Asthma
Medications in the Specialty Program may only be obtained through contracted retail pharmacies store or through the PBM’s home delivery service. You may contact the PBM to determine which retail pharmacy’s are contracted. Specialty medications are limited to a 30-day supply.
A Specialty Care Representative may contact you to facilitate your enrollment in the Specialty Program. Trained Specialty Care pharmacy staff is available 24 hours a day, 7 days a week to assist you or you may enroll directly into the program by calling the PBM’s Customer Service Center.
8.5.
Reimbursement/Filing a Claim
If you or your Dependent purchases Covered Prescription Drugs from a Participating Retail Pharmacy, you pay only the portion shown in the Schedule of Benefits at the time of purchase for covered medications. Should you need to obtain a Covered Prescription Drug prior to obtaining your member ID card, you may file a claim form to obtain reimbursement. The claim form is available on the PBM’s website.
If you or your Dependent purchases Covered Prescription Drugs from a non-Participating Retail Pharmacy, you pay the full cost. These claims are considered not covered under any section of this Plan Description, unless the medication was obtained while traveling in a foreign country and was for an emergency. Claim forms and foreign travel guidelines are available on the PBM’s website.
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Travel Within the United States
International Travel
PBM Services
Benefits are co

Copyright to this resource is held by the creating agency and is provided here for educational purposes only. It may not be downloaded, reproduced or distributed in any format without written permission of the creating agency. Any attempt to circumvent the access controls placed on this file is a violation of United States and international copyright laws, and is subject to criminal prosecution.

EPO PLAN
EFFECTIVE OCTOBER 1, 2009
www.benefitoptions.az.gov
AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time
for clarification purposes without prior notice.
AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
TABLE OF CONTENTS
ARTICLE 1 ESTABLISHMENT OF PLAN 1
ARTICLE 2 ELIGIBILITY AND PARTICIPATION 2
ARTICLE 3 PRE-CERTIFICATION AND NOTIFICATION 16
FOR MEDICAL SERVICES AND PRESCRIPTION MEDICATIONS
ARTICLE 4 CASE MANAGEMENT / DISEASE MANAGEMENT 23
ARTICLE 5 TRANSITION OF CARE 26
ARTICLE 6 OPEN ACCESS TO NETWORK PROVIDERS 27
ARTICLE 7 SCHEDULE OF MEDICAL BENEFITS 28
ARTICLE 8 PRESCRIPTION DRUG BENEFITS 60
ARTICLE 9 EXCLUSIONS AND GENERAL LIMITATIONS 66
ARTICLE 10 COORDINATION OF BENEFITS AND 72
OTHER SOURCES OF PAYMENT
ARTICLE 11 CLAIM FILING PROVISIONS AND 81
APPEALS PROCESS
ARTICLE 12 PLAN MODIFICATION, AMENDMENT, AND 89
TERMINATION
ARTICLE 13 ADMINISTRATION 90
ARTICLE 14 MISCELLANEOUS 93
ARTICLE 15 PLAN IDENTIFICATION 94
ARTICLE 16 DEFINITIONS 96
ARTICLE 1
ESTABLISHMENT OF PLAN
1.1. PURPOSE
The Plan Sponsor established this Plan to provide for the payment or reimbursement of covered medical expenses incurred by Plan Members.
1.2. EXCLUSIVE BENEFIT
This Plan is established and shall be maintained for the exclusive Benefit of eligible Members.
1.3. COMPLIANCE
This Plan is established and shall be maintained with the intention of meeting the requirements of all pertinent laws. Should any part of this Plan Description, for any reason, be declared invalid, such decision shall not affect the validity of any remaining portion, which remaining portion shall remain in effect as if this Plan Description has been executed with the invalid portion thereof eliminated.
1.4. LEGAL ENFORCEABILITY
The Plan Sponsor intends that terms of this Plan, including those relating to coverage and Benefits provided, are legally enforceable by the Members, subject to the Employer’s retention of rights to amend or terminate this Plan as provided elsewhere in this Plan Description.
1.5. NOTE TO MEMBERS
This Plan Description describes the circumstances when this Plan pays for medical care. All decisions regarding medical care are up to a Member and his Physician. There may be circumstances when a Member and his Physician determine that medical care, which is not covered by this Plan, is appropriate. The Plan Sponsor and the Third Party Claim Administrator do not provide or ensure quality of care.
Each network contracts with the in-network providers under this Plan. These providers are affiliated with the EPO Networks and Travel Network and do not have a contract with the Plan Sponsor or Third Party Claim Administrator.
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ARTICLE 2
ELIGIBILITY AND PARTICIPATION
2.1. Eligibility
The Plan is administered in accordance with Section 125 Regulations of the Internal Revenue Code and the Arizona Administrative Code.
Please see ARTICLE 16 for definitions of the terms used below.
The Benefit Services Division will provide potential members reasonable notification of their eligibility to participate in the Plan as well as the terms of participation.
Both the Benefit Services Division and the Medical Network Vendor have the right to request information needed to determine an individual’s eligibility for participation in the Plan.
2.2. Member eligibility
Eligible employees, eligible retirees, and eligible former elected officials may participate in the Plan.
In certain situations, an individual may be eligible to enroll as both a member and a dependent. This individual should enroll either as a member or as a dependent but never both.
2.3. Dependent eligibility
Members’ spouses, domestic partners, unmarried children, and older children may participate in the Plan.
In certain situations, an individual may be eligible to enroll as both a member and a dependent. This individual should enroll either as a member or as a dependent but never both.
In certain situations, an individual may be eligible to participate as a dependent of more than one member. This individual should be enrolled as the dependent of only one of the members.
2.4. Continuing eligibility through COBRA
See Section 4 of this article.
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2.5. Non-COBRA continuing eligibility
The following individuals are eligible for continuing coverage under the Plan.
1. Eligible employee on leave without pay
An employee who is on leave without pay for a health-related reason that is not an industrial illness or injury may continue to participate in the Plan by paying both the state and employee contribution. Eligibility shall terminate on the earliest of the employee:
•
Receiving long-term disability benefits that include the benefit of continued participation;
•
Becoming eligible for Medicare coverage; or
•
Completing 30 months of leave without pay.
An employee who is on leave without pay for other than a health-related reason may continue to participate in the Plan for a maximum of six months by paying both the state and employee contributions.
2. Surviving dependent(s) of insured retiree
Upon the death of a retiree insured under the Plan, the surviving dependents are eligible to continue coverage under the Plan, provided each was insured at the time of the member’s death, by payment of the retiree premium.
If the spouse/domestic partner survives, he/she, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse/domestic partner may be continued indefinitely.
In the case where children/older children, who are eligible dependents of the surviving spouse/domestic partner, survive, they may continue participation in the Plan if enrolled by the surviving spouse/domestic partner as allowed under section 2.3.
In the case where children/older children survive but no spouse/domestic partner survives or the children/older children are not eligible dependents of the spouse/domestic partner, each child/older child, for purposes of Plan administration, will be reclassified as a
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member. As such, each child/older child may enroll dependents as allowed under section 2.3. In this circumstance, coverage for each surviving child/older child may be continued indefinitely.
Please note that a dependent not enrolled at the time of the member’s death may not enroll as a surviving dependent.
3. Surviving spouse/child of insured employee eligible for retirement under the Arizona State Retirement System
Upon the death of an insured employee meeting the criteria for retirement under the Arizona State Retirement System, the surviving spouse and children, provided each was enrolled at the time of the member’s death, are eligible to continue participation in the Plan by payment of the retiree premium.
If the insured spouse survives, he/she, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse may be continued indefinitely.
In the case where insured children, who are eligible dependents of the surviving spouse, survive, they may continue participation in the Plan if enrolled by the surviving spouse as allowed under section 2.3.
In the case where insured children survive but no spouse survives, each child, for purposes of Plan administration, will be reclassified as a member. As such, each child may enroll dependents as allowed under section 2.3. In this circumstance, coverage for each surviving child may be continued indefinitely.
Please note that a child/spouse not enrolled as a dependent at the time of the member’s death may not enroll as a surviving child/spouse.
4. Surviving spouse of elected official or insured former elected official
Upon the death of a former elected official insured under the Plan, the surviving spouse may continue participation in the Plan, provided that he/she was enrolled at the time of the member’s death, by payment of the retiree premium. The surviving spouse, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under section 2.3. Coverage for the surviving spouse may be continued indefinitely.
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Please note that a spouse not enrolled at the time of the former elected official’s death may not enroll as a surviving spouse.
Upon the death of an elected official who would have become eligible for coverage upon completion of his/her term, the surviving spouse may continue participation in the Plan, provided that he/she was enrolled at the time of the elected official’s death, by payment of the retiree premium. The surviving spouse, for purposes of Plan administration, will be reclassified as a member. As such, he/she may enroll dependents as allowed under Section 2.3. Coverage for the surviving spouse may be continued indefinitely.
Please note that a spouse not enrolled at the time of the elected official’s death may not enroll as a surviving spouse.
2.6. Eligibility audit
The Benefit Services Division may audit a member’s documentation to determine whether an enrolled dependent is eligible according to the Plan requirements. This audit may occur either randomly or in response to uncertainty concerning dependent eligibility.
Both the Benefit Services Division and the Medical Network Vendor have the right to request information needed to determine an individual’s eligibility for participation in the Plan.
2.7. Grievances related to eligibility
Individuals may file a grievance with the Director of the Department of Administration regarding issues related to eligibility. To file a grievance, the individual should submit a letter to the Director that contains the following information:
•
Name and contact information of the individual filing the grievance;
•
Nature of the grievance; and
•
Nature of the resolution requested
The Director will provide a written response to a grievance within 60 days.
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2.8. Enrollment procedures and commencement of coverage
New enrollments or coverage changes will only be processed in certain circumstances. Those circumstances are described below.
2.9. Initial enrollment
Once eligible for coverage, potential members have 31 days to enroll themselves and their dependents in the Plan.
It should be emphasized that coverage begins only after an individual has successfully completed the enrollment process. Documentation may be required.
The table below lists pertinent information related to the initial enrollment process.
Category
Must enroll within
31 days of
Enrollment
contact
Coverage begins
on the1
Eligible state employee
date of hire
Agency liaison
first day of first pay period after completion of enrollment
Eligible university employee
date of hire
Human resources office
Please contact the appropriate human resources office
Eligible participating political subdivision employee
date of hire
Human resources office
Please contact the appropriate human resources office
Eligible retiree
date of retirement
Benefit Services Division
first day of first month after completion of enrollment2
Eligible former elected official
date of leaving office or retiring
Benefit Services Division
first day of first month after completion of enrollment
1 Under no circumstance will coverage for a dependent become effective prior to the member’s coverage becoming effective.
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2 For state employees entering retirement and their dependents, coverage begins the first day of the first pay period following the end of coverage as a state employee. This results in no lapse in coverage.
clarification purposes without prior notice.
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Category Must enroll within
31 days of
Enrollment
contact
Coverage begins
on the1
Surviving spouse of elected official or eligible former elected official
date of death
Benefit Services Division
first day of first month after completion of enrollment
2.10.
Open enrollment
Before the start of a new plan year, members are given a certain amount of time during which they may change coverage options. Potential members may also elect coverage at this time. This period is called open enrollment.
In general, open enrollment for eligible employees, retirees and former elected officials is held in August.
At the beginning of each year’s open enrollment period, enrollment booklets are provided to those eligible for coverage under the Plan. These booklets contain information regarding changes in benefits as well as whether a current member is required to re-elect his/her coverage during open enrollment (called a “positive” open enrollment).
Elections must be made before the end of open enrollment. Those elections – or the current elections, if no changes were made and it was not a positive open enrollment - will be in effect during the subsequent plan year.
Coverage for all groups begins on the first day of the new plan year.
It should be emphasized that coverage options change only after an individual has successfully completed the enrollment process. Documentation may be required.
2.11.
Qualified life event enrollment
If a qualified life event occurs, members have 31 days3 to enroll or change coverage options.
Changes made as a result of a qualified life event must be consistent with the event itself. For example, if a dependent child gets married,
3 Pursuant to the Children’s Health Insurance Program (CHIP) Reauthorization Act, individuals who lose Medicaid or CHIP coverage due to ineligibility have 60 days to request enrollment.
clarification purposes without prior notice.
coverage for that child may be immediately discontinued but coverage for another dependent child may not be discontinued until the following open enrollment period or until a qualified life event affecting the second child occurs.
It should be emphasized that coverage options change only after an individual has successfully completed the enrollment process. Documentation may be required.
State employees should contact the appropriate agency liaison when they choose to change coverage options as a result of a qualified life event. University and political subdivision employees should contact the appropriate human resources office. Retirees and former elected officials should contact the Benefit Services Division.
For state employees, most coverage changes become effective on the first day of the first pay period after completion of enrollment. For retirees and former elected officials, most coverage changes become effective on the first day of the first month after completion of enrollment. University and political subdivision employees should contact the appropriate human resources office for information regarding the effective date of coverage changes.
The table below lists pertinent information related to the qualified life event enrollment process. It should be noted that not all qualified life events are listed below.
Type of event
Must enroll/change
coverage within
31 days of:
Coverage/change
in coverage begins
on the4:
Marriage
date of the event
See above
Death of dependent
date of the event
See above
Divorce, annulment, or legal separation
date of the event
See above
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4 University and political subdivision employees should contact the appropriate human resources office for information regarding effective date of coverage changes.
clarification purposes without prior notice.
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Type of event Must enroll/change
coverage within
31 days of:
Coverage/change
in coverage begins
on the4:
Employment status change (beginning employment, termination, strike, lockout, beginning/ ending FMLA, full-time to part-time)
date of the event
See above
Change in residence
date of the event
See above
Loss/gain of dependent eligibility (other than listed below)
date of the event
See above
Newborn5
date of birth
date of birth6
Recently adopted child
date of placement for adoption
date of adoption7
Child recently placed under legal guardianship
date member granted legal guardianship
date member granted legal guardianship7
Child recently placed in foster care
date of placement in foster care
See above
2.12.
Change in cost of coverage
If the cost of benefits increases or decreases during a plan year, the Benefit Services Division may, in accordance with plan terms, automatically change your elective contribution.
When the Benefit Services Division determines that a change in cost is significant, a member may either increase his/her contribution or elect less-costly coverage.
2.13.
Termination of coverage
Coverage for all members/dependents ends at 11:59 p.m. on the date the Plan is terminated. Termination of coverage prior to that time is described in the table below.
5 Born to member or member’s legal spouse.
6 Coverage ends on 31st day after date of birth if member does not enroll newborn in the Plan.
7 Child recently adopted, placed under legal guardianship, or placed in foster care covered from date of adoption only if member subsequently enrolls child in the Plan. clarification purposes without prior notice.
Category
Coverage ends at 11:59 p.m.
on the earliest of:
Eligible state/university employee
•
last day of the pay period for/in which the member:
􀂾􋹭
makes last contribution;
􀂾􋹦
fails to meet the requirements for eligibility; or
􀂾􋹢
becomes an active member of the armed forces of a foreign country; or
•
last day member is eligible for extension of coverage.
Eligible participating political subdivision employee
Please contact the appropriate human resources office
Eligible retiree8/former elected official
•
last day of the month for/in which the member:
􀂾􋹭
makes last premium payment; or
􀂾􋹦
fails to meet the requirements for eligibility.
Eligible long-term disability recipient
•
last day of the month in which the disability benefit ends.
Eligible dependent
•
last day of the pay period in which the dependent child ceases to be a full-time student9;
•
day before dependent child/older child reaches the limiting age;
•
day the dependent:
􀂾􋹤
dies;
􀂾􋹬
loses eligibility for reason other than limiting age; or
􀂾􋹢
becomes an active member of the armed forces of a foreign country; or
•
day the member:
􀂾􋹩
is relieved of a court-ordered obligation to furnish coverage for a dependent child; or
􀂾􋹩
is no longer covered.
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8 excluding long-term disability recipient
clarification purposes without prior notice.
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Category Coverage ends at 11:59 p.m.
on the earliest of:
Eligible employee on leave without pay
•
last day of period in which member becomes eligible for:
􀂾􋹬
long-term disability benefits for which there is eligibility to continue coverage under the Plan; or
􀂾􋹣
coverage under Medicare; or
•
30 months after the leave-without-pay period began.
Surviving child/spouse of eligible retiree
•
last day of the period for which the member makes last payment; or
•
day the surviving child fails to be eligible as a child/older child.
Surviving spouse of elected official or eligible former elected official
•
last day of the period for which the member makes last payment.
2.14.
Continuing eligibility through COBRA
Eligibility of enrolled members/dependents
In accordance with the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA), a member/dependent at risk for losing coverage due to a qualifying event may extend his/her coverage under the Plan for a limited period of time.
To be eligible for COBRA coverage, a member/dependent must be covered under the Plan on the day before the qualifying event. Each covered individual may elect COBRA coverage separately. For example, a dependent child may continue coverage even if the member does not.
Members and dependents would be eligible for COBRA coverage in the event that the state of Arizona files bankruptcy under Title 11 of the U.S. Code.
The table below lists individuals who would be eligible for COBRA coverage if one of the corresponding qualifying events were to occur.
9 If child is not a full-time student for more than one school term, termination is retroactive to the last day of the month in which the full-time status ended. clarification purposes without prior notice.
Category
Duration of COBRA coverage
Qualifying event
Eligible employee, dependent
Up to 18 months10
•
Voluntary or involuntary termination of member’s employment for any reason other than "gross misconduct"; or
•
Reduction in the number of hours worked by member (including retirement)11.
Dependent
Up to 36 months
•
Member dies; or
•
Member and dependent spouse/domestic partner divorce, legally separate, or terminate partnership.
Dependent child/older child
Up to 36 months
•
Dependent child/older child no longer meets eligibility requirements.
2.15.
Subsequent qualifying events
An 18-month COBRA period may be extended to 36 months for a dependent if:
•
Member dies; or
•
Member and dependent spouse/domestic partner divorce, legally separate, or dissolve partnership; or
•
Dependent child/older child no longer meets eligibility requirements.
This clause applies only if the second qualifying event would have caused the dependent to lose coverage under the Plan had the first qualifying event not occurred.
10 If the member and/or dependent is disabled when he/she becomes eligible for COBRA or within the first 60 days of COBRA coverage, duration of coverage may be extended to 29 months. See section 2.4 for special rules regarding disability. 12 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
11 If the member takes a leave of absence qualifying under the Family and Medical Leave Act (FMLA) and does not return to work, the COBRA qualifying event occurs on the date the member notifies ADOA that he/she will not return, or the last day of the FMLA leave period, whichever is earlier.
clarification purposes without prior notice.
2.16.
Eligibility of newly acquired eligible dependents
If the member gains an eligible dependent during COBRA coverage, the dependent may be enrolled in the Plan through COBRA. The member should provide written notification to the Benefit Services Division within 31 days of the qualifying life event. Newly acquired dependents may not enroll in the COBRA coverage after 31 days.
2.17.
Special rules regarding disability
The 18 months of COBRA coverage may be extended to 29 months if a member is determined by the Social Security Administration to be disabled at the time of the first qualifying event or during the first 60 days of an 18-month COBRA coverage period. This extension is available to all family members who elected COBRA coverage after a qualifying event.
To receive this extension, the member must provide the Benefit Services Division with documentation supporting the disability determination within 60 days after the latest of the:
•
Social Security Administration makes the disability determination;
•
Qualifying event occurs; or
•
Date coverage is/would be lost because of the qualifying event.
2.18.
Payment for COBRA coverage
Participants who extend coverage under the Plan due to a COBRA qualifying event must pay 102% of the active premium. Participants whose coverage is extended from 18 months to 29 months due to disability may be required to pay up to 150% of the active premium beginning with the 19th month of COBRA coverage.
COBRA coverage does not begin until payment is made to the COBRA administrator. A participant has 45 days from submission of his/her application to make the first payment. Failure to comply will result in loss of COBRA eligibility.
2.19.
Notification by the member/dependent
Under the law, the Plan must receive written notification of a divorce, legal separation, dissolution of partnership, or child’s/older child’s loss of dependent status, within 60 days of the later of the:
•
Date of the event; or
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clarification purposes without prior notice.
•
Date coverage would be lost because of the event.
Notification must include information related to the member and/or dependent(s) requesting COBRA coverage. Documentation may be required.
COBRA coverage cannot be elected if proper notification is not made.
Written notification should be directed to:
ADOA Benefit Services Division
100 N. 15th Avenue, Suite 103
Phoenix, AZ 85007
2.20.
Notification by the Plan
The Plan is obligated to notify each participant of his/her right to elect COBRA coverage when a qualifying event occurs.
2.21.
Electing COBRA coverage
Information related to COBRA coverage and enrollment may be obtained through an agency liaison or by calling ADOA Benefit Services Division at 602-542-5008 or 1-800-304-3687 or by writing to the address provided in Section F.
2.22.
Early termination of COBRA coverage
The law provides that COBRA coverage may, for the reasons listed below, be terminated prior to the 18-, 29-, or 36-month period:
•
The Plan is terminated and/or no longer provides coverage for eligible employees;
•
The premium is not received within the required timeframe;
•
The member enrolls in another group health plan that does not exclude/limit coverage for pre-existing conditions; or
•
The member becomes eligible for Medicare.
For members whose coverage was extended to 29 months due to disability, COBRA coverage will terminate after 18 months or when the Social Security Administration determines that the member is no longer disabled.
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2.23.
Contact information for the COBRA administrator
COBRA-related questions or notifications should be directed to the Benefit Services Division.
2.24.
Certificate of creditable coverage
When COBRA coverage ends, the Medical Network Vendor will send a certificate of creditable coverage. This certificate confirms that each participant was covered under the Plan and for what length of time. The certificate may be used as credit against a new plan’s pre-existing condition limitation.
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ARTICLE 3
PRE-CERTIFICATION AND NOTIFICATION FOR MEDICAL SERVICES AND PRESCRIPTION MEDICATION
3.1.
Pre-Certification and Notification
Pre-certification is the process of determining the Medical Necessity of services before the services are incurred. This ensures that any medical care a member receives meets the Medical Necessity requirements of the Plan. The definition and requirements of Medical Necessity are identified in Article 16. Pre-Certification is initiated by calling the toll-free Pre-Certification phone number shown on your ID card and providing information on the planned medical services. Pre-Certification may be requested by you, your dependent or your Physician. However, the Member is ultimately responsible to ensure Pre-Certification is obtained.
All decisions regarding medical care are up to a Patient and his/her Physician. There may be circumstances when a Patient and his/her Physician determine that medical care, which is not covered by this Plan, is appropriate. The Plan Sponsor and the Third Party Claim Administrator do not provide or ensure quality of care.
Pre-certification should be initiated for specific services are noted in the Plan Description by calling the Medical Network Vendor Customer Service Center and providing information on the planned medical services. The patient or the physician/facility may request pre-certification; however, the member is ultimately responsible to ensure pre-certification is obtained.
If Pre-certification is not obtained before planned medical services are incurred, the submitted claim will held and a letter will be issued notifying you and the provider that pre-certification is required before claim processing can continue. This must be initiated by calling the Medical Network Vendor and providing information on the incurred medical services. If pre-certification is not initiated within 60 days of the first pend letter, the claim will be denied.
3.2.
Treatment by Participating Providers
If you do not Pre-Certify as required above, the Claims Administrator will review the claims submitted for Medical Necessity after the services have been rendered. If the claim is denied based on the plan provisions or Medical Necessity, the member is responsible for payment.
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clarification purposes without prior notice.
3.3.
Treatment by Non-Participating Providers
Except in emergency situations, treatment provided by a non-Participating Provider is not covered by the Plan. However, there may be rare circumstances where the Plan will provide coverage for services rendered by a non-Participating Physician (e.g. there is only one specialist who is able to treat your specific disease and that specialist does not contract with the network). The only way you can obtain coverage in these instances is by obtaining Pre-Certification.
3.4.
Medical Services Inpatient Admissions
Pre-Certification for Inpatient admissions refers to the process used to certify the medical necessity and length of any Hospital Confinement as a registered bed patient. Pre-Certification is performed through a utilization review program by a Medical Management Organization with which the State of Arizona has contracted. Pre-Certification should be requested by you, your dependent or an attending physician by calling the Pre-Certification phone number shown on your ID card prior to each inpatient Hospital admission. Pre-Certification should be requested, prior to the end of the certified length of stay, for continued inpatient Hospital Confinement.
You should start the Pre-Certification process by calling the Medical Management Organization prior to an elective admission, prior to the last day approved for a current admission, or in the case of an emergency admission, by the end of the second scheduled business day after the admission. The Medical Management Organization will continue to monitor the confinement until you are discharged from the Hospital. The results of the review will be communicated to the Member, the attending Physician, and the Third Party Claim Administrator.
The Medical Management Organization is an organization with a staff of Registered Nurses and other trained staff members who perform the Pre-Certification process in conjunction with consultant Physicians.
3.5.
Other Services & Supplies
Pre-Certification should be requested for those services that require Pre-Certification. Pre-Certification should be requested by you, your dependent or your physician by calling the toll-free phone number shown your ID card prior to receiving services. Services that should be Pre-Certified include, but are not limited to:
1.
Inpatient services in a hospital or other facility (such as hospice or skilled nursing facility);
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2.
Inpatient maternity services in a hospital or birthing center exceeding the Federally mandated stay limit of 48 hours for a normal delivery or 96 hours for a c-section;
3.
A separate Pre-authorization is required for a newborn in cases where the infant has been diagnosed with a medical condition requiring in-patient services independent of the maternity stay.
4.
Outpatient surgery in a hospital or ambulatory surgery center as required by the Third Party Claims Administrators.
5.
Accidental dental services;
6.
Dental confinements/anesthesia required due to a hazardous medical condition;
7.
Mental/nervous and substance abuse services (both inpatient and outpatient);
8.
Outpatient and ambulatory magnetic resonance imaging (MRI/MRA), PET Scans, ECT, BEAM (Brain Electrical Activity Mapping), Gamma Knife;
9.
Non-emergency ambulance transportation;
10.
Organ transplant services;
11.
Cancer clinical trials;
12.
Chronic Pain management treatment (including biofeedback);
13.
Infusion/IV Therapy in an Outpatient setting to include: Infliximab (Remicade), Alefacept (Amevive), and Etanercept (Enbrel);
14.
Injectable medication in the Physician’s office to include but not limited to Alefacept (Amevive), Etanercept (Enbrel), Sodium Hyaluronate (Hyalgan, Synvisc), Infliximab (Remicade), Omalizumab (Xolair), Lupron, Syranel, Forteo, Lupron Depot;
15.
Home health, including hospice, and parenteral;
16.
Outpatient and ambulatory cardiac testing, angiography, PFT, 23-hour sleep studies, video EEG;
17.
Rental of Durable Medical Equipment which is expected to have a purchase price of $1000 or more;
18.
Purchase of Durable Medical Equipment and prosthetics costing more than $1000;
19.
Foot Orthotic devices and inserts (covered only for diabetes mellitus and any of the following complications involving the foot: Peripheral neuropathy with evidence of callus formation; or history of pre-ulcerative calluses; or history of previous ulceration; or foot deformity; or previous
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amputation of the foot or part of the foot; or poor circulation.);
20.
Repair or replacement of prosthetics;
21.
End Stage Renal Disease services (including dialysis);
22.
Services not available through an in-network provider;
23.
Rehabilitation therapy in excess of 60 visits per Member per Plan Year;
24.
Services which have a potential for a cosmetic component, including but not limited to, blepharoplasty (upper lid), breast reduction, breast reconstruction, ligation (vein stripping), and sclerotherapy.
25.
CAT/CT imagery
26.
Injections given during an office visit that cost over $350.00 per injection.
27.
Cochlear Implants.
28.
Treatment for Autism Spectrum Disorder.
3.6.
Notification of 23-hour observation admissions
While Pre-Certification is not required for 23-hours observation admissions, we encourage you to contact the Medical Management Organization if you will be receiving these services. This will assist in the Pre-Certification process should the admission exceed 23 hours.
3.7.
Notification of maternity services
While Pre-Certification is not required for maternity services in the physician’s office, outpatient, and inpatient within federally mandated stay limits, we encourage you to contact the Medical Management Organization if you will be receiving any maternity services. This will assist in the Pre-Certification process should Inpatient services be required that exceed 48 hours for a normal delivery and 96 hours for a c-section. Notification also enables the Medical Management Organization staff to assist you with education and/or resources to maintain your health during your pregnancy. Inpatient maternity services are subject to a $250.00 maternity delivery co-payment per child. The $250.00 co-payment will be reimbursed if the member enrolls in the health pregnancy program prior to the 12th week of pregnancy and completes the program.
3.8.
Prescription Medications
For the purposes of member safety, certain prescriptions require “prior authorization” or approval before they will be covered, including but not limited to an amount/quantity that can be used within a set timeframe, an age limitation has been reached and/or exceeded or appropriate utilization must be determined. The Pharmacy Benefit Management
19 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
Vendor (PBM), in their capacity as pharmacy benefit manager, administers the clinical prior authorization process.
Clinical Prior Authorization (CPA) may be initiated by the pharmacy, the physician, you, and/or your covered family members by calling the PBM. The pharmacy may call after being prompted by a medication denial stating “Prior Authorization required.” The pharmacy may also pass the information on to you and require you to follow-up.
After the initial call is placed, the Clinical Services Representative obtains information and verifies that the plan participates in a CPA program for the particular drug category. The Clinical Services Representative generates a drug specific form and faxes it to the prescribing physician. Once the fax form is received by the Clinical Call Center, a pharmacist reviews the information and approves or denies the request based on established protocols. Determinations may take up to 48 hours from the PBM’s receipt of the completed form, not including weekends and holidays.
If the prior authorization request is APPROVED, the PBM Clinical Service Representative calls the person who initiated the request and enters an override into the PBM processing system for a limited period of time. The pharmacy will then process your prescription.
If the prior authorization request is DENIED, the PBM Clinical Call Center pharmacist calls the person who initiated the request and sends a denial letter explaining the denial reason. The letter will include instructions for appealing the denial. For more information see the “Appeals Procedures” section of this document.
The criteria for the Prior Authorization program are based on nationally recognized guidelines; FDA approved indications and accepted standards of practice. Each specific guideline has been reviewed and approved by the PBM Pharmacy and Therapeutics (P&T) Committee for appropriateness. Prescription medications that require prior authorization prior to dispensing include but are not limited to:
1.
Anabolic steroids – injectable (Deca-Durabolin®, Virilon IM®);
2.
Anabolic Steroids - Oral (Anadrol-50®, Android Testred®, Oxandrin®, Winstrol®);
3.
Anabolic Steroids – Topical (Androderm®, Androgel®, Testoderm®);
4.
Botulinum Toxins (Myobloc®, Botox®);
5.
Lamisil®;
6.
Sporanox®; and
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Medication(s) included in medication management programs, including but not limited to, an amount or quantity that can be used within a set timeframe or an age limitation, may be subject to prior authorization. Medication Management programs are subject to change and are maintained and updated as medications are FDA approved within the defined therapeutic class and as clinical evidence requires. Medications subjected to prior authorization resulting from medication management programs include, but are not limited to:
1.
Topical Anti-acne products after the age of 24 (e.g. Retin-A®, Avita®, Differin®);
2.
Medications for Attention Deficit Hyperactivity Disorder/ Narcolepsy after the age of 19 (e.g. Dexedrine®, Ritalin®, Cylert®);
3.
Oral Antiemetics beyond defined quantity limitations (e.g. Kyrtil®, Zofran®);
4.
Medications to treat insomnia beyond defined quantity limitations (e.g. Ambien®, Restoril®, Sonata®); and
5.
Medications used to treat migraine headaches beyond defined quantity limitations (e.g. Imitrex®)
A certain class of medications will be managed through the Pharmacy Benefit Management Vendor’s Specialty Pharmacy Program. For more information, on what is covered see the “Specialty Pharmacy” section of this document. Medications that may be included in this program are used to treat chronic or complex health conditions, may be difficult to administer, may have limited availability, and/or may require special storage and handling. A subset of the medications included in the PBM Specialty Pharmacy program requires prior authorization and include, but are not limited to:
1.
Xolair®;
2.
Remicade®, Amevive®, Enbrel®, Kineret®, Humira®, Raptiva®;
3.
Hyalgan ®, Supartz® ,Synvisc®;
4.
Forteo® ;
5.
Lupron®, Synarel®;
6.
Lupron Depot®, Viadur®, Zoladex®, Eligard®, Trelstar®;
7.
Synagis®; and
8.
Growth Hormones.
To confirm whether you need prior authorization and/or to request a prior authorization, call the Pharmacy Benefit Management Vendor listed on your ID card. Please have the information listed below when initiating your request for prior authorization:
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•
Name of your Medication
•
Physician’s Name
•
Physician’s Phone Number
•
Physician’s Fax Number, if available
•
Member ID number (from your card)
•
Rx Group ID number (from your card)
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ARTICLE 4
CASE MANAGEMENT / DISEASE MANAGEMENT AND INDEPENDENT MEDICAL ASSESSMENT
4.1.
Case Management
Case Management is a service provided through an organization contracted with the State of Arizona, which assists individuals with treatment needs that extend beyond the acute care setting. The goal of Case Management is to ensure that patients receive appropriate care in the most effective setting possible whether at home, as an outpatient, or an inpatient in a hospital or specialized facility. Should the need for Case Management arise, a Case Management professional will work closely with the patient, his or her family and the attending physician to determine appropriate treatment options which will best meet the patient’s needs and keep costs manageable. The Case Manager will help coordinate the treatment program and arrange for necessary resources. Case Managers are also available to answer questions and provide ongoing support for the family in times of medical crisis.
Case Managers are Registered Nurses (RNs) and other credentialed health care professionals, some trained in a clinical specialty area such as high risk pregnancy or mental health, and others who work as generalists dealing with a wide range of conditions in general medicine and surgery. In addition, Case Managers are supported by physician advisors who offer guidance on up-to-date treatment programs and medical technology. While the Case Manager may recommend alternate treatment programs and help coordinate needed resources, the patient’s attending physician remains responsible for ordering and guiding the actual medical care.
You, you’re dependent or an attending physician may request Case Management services by calling the toll-free phone number shown on your ID card during normal business hours, Monday through Friday. In addition, the Third Party Claim Administrator or a utilization review program may refer an individual for Case Management.
Each case is assessed to determine whether Case Management is appropriate. You or your Dependent will be contacted by an assigned Case Manager who explains in detail how the program works.
Participation in the program is voluntary – no penalty or benefit reduction is imposed if you do not wish to participate in Case Management.
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Following an initial assessment, the Case Manager works with you, your family and physician to determine the needs of the patient and to identify what alternate treatment programs are available. (For example, in-home medical care in lieu of extended hospital convalescence.) You are not penalized if the alternate treatment program is not followed.
The Case Manager arranges for alternate treatment services and supplies, as needed. (For example, nursing services or a hospital bed and other durable medical equipment for the home.)
The Case Manager also acts as a liaison between the Third Party Claim Administrator, the patient, his or her family and physician as needed. (For example, by helping you to understand a complex medical diagnosis or treatment plan.)
Once the alternate treatment program is in place, the Case Manager continues to manage the case to ensure the treatment program remains appropriate to the patient’s needs.
While participation in Case Management is strictly voluntary, Case Management professionals may offer quality, cost-effective treatment alternatives, as well as provide assistance in obtaining needed medical resources and ongoing family support in a time of need.
4.2.
Disease Management
Disease Management is a service provided through an organization contracted with the State of Arizona, which assists Members with treatment needs for chronic conditions. Disease Management is a voluntary program – no penalty or benefit reduction is imposed if you do not wish to participate in Disease Management.
If you are being treated for certain conditions which have been initiated under this program, you will be contacted by the Disease Management staff with further information on the program. The goal of Disease Management is identification of areas in which the staff may assist you with education and/or resources to maintain your health.
4.3.
Independent Medical Assessment
The Plan reserves the right to require independent medical assessments to review appropriateness of treatment and possible alternative treatment options for any member participating on the plan. The individual medical assessments may take place on site or via medical record review and will be carried out by a licensed/board certified
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medical doctor specializing in the area of treatment rendered to the member. Independent medical assessments may be utilized in instances where current treatment is atypical for the diagnosis, where the current treatment is complex and involves many different providers, and/or the current treatment is of high cost to the Plan. If an independent medical assessment is required, the enrolled person will be notified in writing.
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ARTICLE 5
TRANSITION OF CARE
5.1
Transition of Care
If you are a new Member, upon written request to the Medical Management Organization, you may continue an active course of treatment with your current health care provider who is not a Participating Provider and receive in-network benefit levels during a transitional period after the effective date of coverage if one of the following applies:
1.
You have a life threatening disease or condition;
2.
If you have been receiving care and a continued course of covered treatment is Medically Necessary, you may be eligible to receive “transitional care” from the non-Participating Provider;
3.
Entered the third trimester of pregnancy on the effective date of enrollment; or
4.
If you are in your second trimester of pregnancy and your doctor agrees to accept our reimbursement rate and to abide by the Plan’s policies and procedures and quality assurance requirements.
There may be additional circumstances where continued care by a provider no longer participating in the network will not be available, such as when the provider loses his license to practice or retires.
Transitions of Care request forms are available by contacting the Medical Network Vendor Customer Service Center or by visiting their Website.
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ARTICLE 6
OPEN ACCESS TO PROVIDERS
Open access refers to how you “access” physicians. This plan does not require members to designate a Primary Care Physician (PCP) and members may schedule an appointment directly with a specialist of his/her choosing; however, the specialist MUST be contracted within your medical plan provider network.
Members may still choose to maintain a primary relationship with one physician and are encouraged to do so, but are not required to. For assistance finding a health care provider, contact the member services office at the number listed on your ID card.
In order for eligible services to be covered by this plan, it is the member’s responsibility to confirm the facilities, specialists and physicians they use are contracted with his/her medical plan network of providers at the time services are provided.
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ARTICLE 7
SCHEDULE OF MEDICAL BENEFITS
COVERED SERVICES AND SUPPLIES
7.1.
Schedule of Medical Benefits Covered Services and Supplies Chart
It is important to note that all inpatient services, specific outpatient services, and certain prescription medications require Pre-Certification. Please refer to Article 3 of this document for details.
Co-payment
Physician Visits
Adult Immunizations. Refer 7.29. Immunizations for a complete list of Adult Immunizations.
$15.00
Annual Routine Physical
1 visit per member per plan year limited to $1500 per Member per Plan Year
$15.00
Chiropractic & Osteopathic
Includes all spinal manipulation or treatment. Limited to 20 visits per Member per Plan year (combined in-network and out-of-network) subject to being Medically Appropriate.
$15.00
Hearing Exam
One per Member per Plan Year
$15.00
Obstetrics & Gynecology OB/GYN
$10.00
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Co-payment
Physician Visits (one co-pay per day per provider)
(General Practice, Family Practice and Internal Medicine, Chiropractor, Speech Therapy*, Occupational Therapy*, Cardiac Therapy*, Respiratory Therapy*, and Physical therapy*, and Pediatrician ) *Subject to the benefit limitations described under Short-term Rehabilitative Therapy section 7.52.
Specialists Visit
$15.00
$30.00
Prenatal Care and Program
For initial diagnosis; covered at 100% thereafter
$10.00
Rehabilitation Services, Short-Term, limited to 60 visits per Member per Plan Year for all therapy types listed combined. Additional visits subject to medical necessity with Pre-Certification. Includes: Physical therapy, Occupational therapy, Speech therapy, Respiratory therapy, and Cardiac therapy.
$15.00
Urgent Care Center
$40.00
Well-Child through 23 months. (Co-pay is waived if the only service rendered is a well-child immunization).
Age 2 and over: 1 visit per Member per Plan Year (includes laboratory and radiology).
$15.00
Well-Man Care (OV, PSA Blood test). 1 visit per Member per Plan Year (includes laboratory and radiology).
$15.00
Well-Woman Exam (OV, PAP). 1 visit per Member per Plan Year (includes laboratory and radiology). *Copayment is subject to the type of provider at visit.
$15.00 PCP*
$10.00 OB-GYN*
clarification purposes without prior notice.
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Co-payment
Hospital Services
Ambulance (for medical emergency or required interfacility transport)
No charge
Hospice Care
Inpatient facility or home hospice for life expectancy of 6 months or less.
No charge
Hospital Admission
*Hospital in-patient admission co-payment: would apply to any in-patient hospital admission with or without an authorization excluding: Subacute Care, Post-Acute Care, and Hospice. Subacute Care would include but not be limited to: long-term care, hospital-based skilled nursing facilities (SNFs), and free standing SNFs.
$150.00*
Hospital Emergency Room (In-network and out-of network). Must be a Medical Emergency as defined by the Plan. *waived if admitted to hospital directly from emergency room but subject to hospital admission co-payment.
$125.00*
Intensive Care Unit
No charge
Maternity Admission
*Reimbursed if patient completes the “Healthy Pregnancy” program (must enroll by the 12th week of pregnancy and complete the program).
$250.00* per baby
Non-emergency ambulance transportation with Pre-Certification.
No charge
Private rooms when medically necessary
No charge
Radiology and Laboratory
No charge
Semi-Private Room & Board. The Plan allows charges up to 90% of the Private room rate if the facility has no Semi-Private rooms.
No charge
Skilled Nursing Facility/Rehabilitation
Hospital or sub-acute facilities.
90-day limit per Member per Plan Year.
No charge
clarification purposes without prior notice.
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Co-payment
Surgery/Anesthesia/Asst Surgeon (inpatient)
No charge
Mental Health Services
Mental/Nervous, and Substance Abuse Office Visit
$15.00
Mental/Nervous, and Substance Abuse (inpatient & residential)
$150.00
Other Services
Allergy Testing
$30.00
Antigen Administration
Desensitization/treatment
$30.00
Autism Spectrum Disorder Services
Behavioral therapy services limited to the following plan year maximum
a.
For ages 0-8 $50,000
b.
For ages 9-16 $25,000
$15.00
Bariatric Surgery
20% coinsurance
Contraceptive Appliances obtained at a Physician’s office.
$15.00
Corrective Appliances, Prosthetics, Medically Appropriate foot orthotics.
Foot orthotics limited to diabetic treatment.
No charge
Diagnostic Testing, including Laboratory and Radiology
No charge
Durable Medical Equipment (DME)
Medically Necessary.
No charge
Family Planning Services
Voluntary Tubal ligation (outpatient facility)
Vasectomy (physician’s office)
Implantable contraceptive products (limited to one per every five years)
$50.00
$30.00
$30.00
clarification purposes without prior notice.
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Co-payment
Hearing Aids
Limited to $1,500 for each ear per Member per Plan Year.
No charge
Home Health/Home Infusion Care.
Limited to 42 visits per member per Plan Year as described in section 7.27. Home Health Services.
No charge
Mammography screening
Age 35-39 one baseline
Age 40 and older annually
Non-routine services covered more frequently based on recommendation of the Member’s Physician.
No charge
Medical Foods/Metabolic Supplements and Gastric Disorder Formula. Limited to 75% to $20,000 max per Member per Plan Year.
25% coinsurance
up to $1,000 per individual or $2,000 per family Out-of-Pocket Maximum per plan year.
Organ and Tissue Transplantation and Donor Coverage. No coverage if Member is an organ donor for a recipient other than a Member enrolled under this Plan. Travel & lodging expenses are limited to $10,000 per transplant. Travel and lodging are not covered if the Member is a donor.
No charge
Ostomy supplies
No charge
Surgery Facility and Associated Physician fees
In primary physician’s office
In a specialist office
In Freestanding ambulatory facility
In hospital outpatient surgical center
$15.00
$30.00
$50.00
$50.00
clarification purposes without prior notice.
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Co-payment
PRESCRIPTION MEDICATION AND DIABETIC SUPPLIES AS IDENTIFIED UNDER ARTICLE 8.
Diabetic Supplies includes insulin, lancets, insulin syringes/needles, pre-filled cartridges, urine test strips, blood glucose testing machines, blood sugar test strips, and alcohol swabs.
Available through Mail Order and retail.
Smoking cessation aids both prescribed and over-the counter will be covered at a maximum of $500 per member per lifetime. All co-pays based on the formulary will apply. Member must have a prescription and present to an in-network pharmacy for the aid to be covered. Only FDA approved aids will be covered.
$500 maximum per lifetime
Retail Pharmacy (30-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$10.00
$20.00
$40.00
Mail Order (90-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$20.00
$40.00
$80.00
Retail (90-day supply)
Generic
Formulary Brand
Non-Formulary Brand
$25.00
$50.00
$100.00
7.2.
DETERMINATION OF ELIGIBLE EXPENSES
Subject to the exclusions, conditions, and limitations stated in this document, the Plan will pay Benefits to, or on behalf of, a Member for covered Medical Expenses described in this section, up to the amounts stated in the Schedule of Benefits.
The Plan will pay Benefits for the Reasonable and Customary Charges or the contracted fee as determined by the Provider’s contract with the Network for services and supplies which are ordered by a Physician. clarification purposes without prior notice.
Services and supplies must be furnished by an Eligible Provider and be Medically Necessary.
The obligation of the Plan shall be fully satisfied by the payment of allowable expenses in accordance with the Schedule of Benefits. Benefits will be paid for the reimbursement of medical expenses incurred by the Member if all provisions mentioned in this document are satisfied.
All payments made under this Plan for allowable charges will be limited to Reasonable and Customary Charges or the contracted fee as determined by the Provider’s contract with the Network minus all co-pays and coinsurance stated in the Schedule of Benefits.
7.3.
Out-of-Pocket Maximum
Out-of-Pocket Expenses are Covered Expenses incurred for charges made by a Provider for which no payment is made on a portion of the claim because of the coinsurance factor for metabolic supplements.
The following do not apply to the accumulation of the maximum out-of-pocket:
1.
Prescription co-pays;
2.
All flat dollar medical co-pays such as, office visit, urgent care, emergency room, and rehabilitation therapy;
3.
Charges in excess of Reasonable and Customary; and
4.
All charges associated with a non-covered service.
When a Member has incurred Out-of-Pocket Expenses of $1,000 in a Plan Year, benefits for Covered Expenses normally payable at 75% and incurred during the rest of that Plan Year will be payable at the rate of 100% not to exceed any stated Plan maximum.
When two or more Members enrolled under a policy have incurred a combined amount of Out-of-Pocket Expenses of $2,000 in a Plan Year, benefits for you and all of your Dependents for Covered Expenses normally payable at 75% and incurred during the rest of that Plan Year will be payable at the rate of 100% not to exceed any stated Plan maximum.
All co-pays noted that are not a percentage coinsurance will continue to apply regardless of the Maximum Out-of-Pocket amount.
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7.4.
Notification, Proof of a Claim, and Payment
Inpatient hospitalization for any Emergency Services or Urgent Care requires notification to and Pre-Certification by the Medical Management Organization.
Notification of inpatient hospitalization is required as soon as reasonably possible, but no later than the second business day after admission. This requirement shall not cause denial of an otherwise valid claim if you could not reasonably comply, provided that notification is given to the Medical Management Organization as soon as reasonably possible.
Coverage for Emergency Services and Urgent Care received through non-Participating Providers shall be limited to covered services to which you would have been entitled under the Plan, and shall be reimbursed at the prevailing Reasonable and Customary rate for self-pay patients in the area where the services were provided.
Claims and supporting documentation submitted for reimbursement must meet the Timely Filing requirements and be received within one (1) year from the date the services were rendered. Claim forms are available on the Third Party Administrator website or by calling the Customer Service Center.
Foreign Claims: Request for reimbursement of foreign claims must include the following information: Employee name, member identification number, patient name, date of service, provider name and address, detailed description of the services rendered, charges, and the currency in which the charges are being reported. Foreign travel guidelines are available on the Third Party Administrator website.
7.5.
Covered Expenses
The term Covered Expenses means the expenses incurred by or on behalf of a person, if they are incurred after he becomes insured for these benefits and prior to the date coverage ends. Expenses incurred for such charges are considered Covered Expenses to the extent that the services or supplies provided are recommended by a Physician and are essential for the necessary care and treatment of a non-Occupational Injury or a Sickness.
The Covered Expenses available to a Member under this plan are described below. Any applicable Co-payments and other limits are identified in the Schedule of Benefits. Unless otherwise authorized in writing by the Plan, Covered Expenses are available to Member/Participants only if:
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1.
They are Medically Appropriate and not specifically excluded in this Article or any other Article; and
2.
Pre-Certification is obtained from the Plan by the member or provider, for those services that require Pre-Certification. To obtain Pre-Certification call the number on your ID card.
All non-emergency services within the network Service Area must be incurred at a Participating Provider. All non-emergency services outside of the network Service Area must be incurred at a Travel Network Participating Provider.
If a Member uses Participating Providers for facility and physician services for a given procedure, any assistant surgeon, anesthesiologist, radiologist, and pathologist charges in connection with that procedure will be payable at the in-network level of benefits even if rendered by non-Participating Providers. During an inpatient admission, if a consultation is required by a specialist on call at the facility causing the member to have no control over the provider chosen, charges in connection with the consult will be payable at the in-network level of benefits even if rendered by non-Participating Providers. Covered charges will be reimbursed at in-network benefit levels subject to Reasonable and Customary rates.
7.6.
Autism Spectrum Disorder Services
Behavioral therapy is only covered for the treatment of Autism spectrum Disorder as defined in Article 16. The following services are excluded Sensory Integration, LOVAAS Therapy and Music Therapy. All services are subject to the following plan year maximums:
a.
For ages 0-8 $50,000
b.
For ages 9-16 $25,000
If multiple services are provided on the same day by different Providers, a separate Co-payment will apply to each Provider.
7.7.
Physician Services
Physician Services are diagnostic and treatment services provided by Participating Physicians and Other Participating Health Professionals, including office visits, periodic health assessments, well-child care and routine immunizations provided in accordance with accepted medical practices, hospital care, consultation, and surgical procedures.
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clarification purposes without prior notice.
7.8.
Inpatient Hospital Services
Inpatient hospital services are services provided for evaluation or treatment of conditions that cannot be adequately treated on an ambulatory basis or in another Participating Health Care Facility. Inpatient hospital services include semi-private room and board; care and services in an intensive care unit; drugs, medications, biologicals, fluids, blood and blood products, and chemotherapy; special diets; dressings and casts; general nursing care; use of operating room and related facilities; laboratory and radiology services and other diagnostic and therapeutic services; anesthesia and associated services; inhalation therapy; radiation therapy; admit kit; and other services which are customarily provided in acute care hospitals. Inpatient hospital services also include Birthing Centers.
7.9.
Outpatient Facility Services
Outpatient facility services are services provided on an outpatient basis, including: diagnostic and/or treatment services; administered drugs, medications, fluids, biologicals, blood and blood products; inhalation therapy; and procedures which can be appropriately provided on an outpatient basis, including certain surgical procedures, anesthesia, and recovery room services.
7.10.
Emergency Services and Urgent Care
In the event of an emergency, get help immediately. Go to the nearest emergency room, the nearest hospital or call or ask someone to call 911 or your local emergency service, police or fire department for help. You do not need a referral from your Physician for Emergency Services, but you should call your Physician as soon as possible for further assistance and advice on follow-up care. If you require specialty care or a hospital admission, contact the Medical Management Organization to obtain necessary authorizations for care or hospitalization.
If you receive Emergency Services outside the Service Area, you must notify the Third Party Claim Administrator as soon as reasonably possible. We may arrange to have you transferred to a Participating Provider for continuing or follow-up care if it is determined to be medically safe to do so.
“Emergency Services” are defined as a medical or behavioral condition of sudden onset that manifests itself by acute symptoms of sufficient severity (including severe pain) such that a person who possesses an average knowledge of health and medicine could reasonably expect the absence of immediate medical attention to result in placing the health of the insured person in serious jeopardy, serious impairment to bodily
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functions, serious disfigurement of the insured person, serious impairment of any bodily organ or part of the insured person, or in the case of a behavioral condition, placing the health of the insured person or other persons in serious jeopardy.
Examples of emergency situations include uncontrolled bleeding, seizures or loss of consciousness, shortness of breath, chest pains or severe squeezing sensations in the chest, suspected overdose of medication or poisoning, sudden paralysis or slurred speech, burns, cuts, and broken bones. The symptoms that led you to believe you needed emergency care, as coded by the provider and recorded by the hospital on the UB92 claim form or its successor, or the final diagnosis, whichever reasonably indicated an emergency medical condition, will be the basis for the determination of coverage, provided such symptoms reasonably indicate an emergency. You are covered for at least a screening examination to determine whether an emergency exists. Care up and through stabilization for an emergency situation is covered without prior authorization.
For Urgent Care services, you should take all reasonable steps to contact your Physician for direction and you must receive care from a Participating Provider, unless otherwise authorized by the Plan. If you are traveling outside of the network’s service area in which you are enrolled, you should, whenever possible, contact the Plan or your Physician for direction and authorization prior to receiving services.
“Urgent Care” is defined as medical, surgical, hospital and related health care services and testing which are not Emergency Services, but which are determined by the Plan in accordance with generally accepted medical standards to have been necessary to treat a condition requiring prompt medical attention. This does not include care that could have been foreseen before leaving the immediate area where you ordinarily receive and/or are scheduled to receive services. Such care includes but is not limited to: dialysis, scheduled medical treatments or therapy, or care received after a Physician’s recommendation that you should not travel due to any medical condition.
7.11.
Continuing or Follow-up Treatment
Continuing or follow-up treatment by providers out of the Service Area is not covered unless it is Pre-Certified by the Medical Management Organization.
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7.12.
Ambulance Service
Ambulance services to/from an appropriate provider or facility are covered for emergencies. Pre-Certification for non-emergency ambulance services may be obtained from the Medical Management Organization by a provider that is treating the Member.
Covered Expenses include charges for licensed ambulance service to or from the nearest Hospital where the needed medical care and treatment can be provided.
7.13.
Bariatric Surgery
The plan covers the following bariatric surgery procedures: open roux-en-y gastric bypass (RYGBP), laparoscopic roux-en-y gastric bypass (RYGBP), laparoscopic adjustable gastric banding (LAGB), open biliopancreatic diversion with duodenal switch (BPD/DS), and laparoscopic biliopancreatic diversion with duodenal switch (BPD/DS) if all the following criteria are met:
1. The patient must have a body-mass index (BMI) ≥35.
2. Have at least one co-morbidity related to obesity
3. Previously unsuccessful with medical treatment for obesity. The following medical information must be documented in the patient's medical record:
Active participation within the last two years in one physician –supervised weight-management program for a minimum of six months without significant gaps. The weight-management program must included monthly documentation of all of the following components:
a. Weight
b. Current dietary program
c. Physical activity (e.g., exercise program)
4. In addition, the procedure must be performed at an approved facility that is credentialed by your Health Network to perform bariatric surgery.
5. The member must be 18 years or older, or have reached full expected skeletal growth.
If treatment was directly paid or covered by another plan medically necessary adjustments will be covered.
The following bariatric procedures are excluded:
1. Open vertical banded gastroplasty.
2. Laparoscopic vertical banded gastroplasty.
3. Open sleeve gastrectomy.
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4. Laparoscopic sleeve gastrectomy.
5. Open adjustable gastric banding.
7.14.
Breast Reconstruction and Breast Prostheses
Following a mastectomy, the following services and supplies are covered:
1.
Surgical services for reconstruction of the breast on which the mastectomy was performed;
2.
Surgical services for reconstruction of the non-diseased breast to produce symmetrical appearance;
3.
Post-operative breast prostheses; and
4.
Mastectomy bras/camisoles and external prosthetics that meet external prosthetic placement needs.
During all stages of mastectomy, treatments of physical complications, including lymphedema, are covered.
7.15.
Cancer Clinical Trials
Coverage shall be provided for Medically Appropriate covered patient costs that are directly associated with a cancer clinical trial that is offered in the State of Arizona and in which the Member participates voluntarily. A cancer clinical trial is a course of treatment in which all of the following apply:
1.
The treatment is part of a scientific study of a new therapy or intervention that is being conducted at an institution in the State of Arizona, that is for the treatment, palliation or prevention of cancer in humans and in which the scientific study includes all of the following: (a) specific goals; (b) a rationale and background for the study; (c) criteria for patient selection; (d) specific directions for administering the therapy and monitoring patients; (e) definition of quantitative measures for determining treatment response; and (f) methods for documenting and treating adverse reactions;
2.
The treatment is being provided as part of a study being conducted in a phase I, phase II, phase III or phase 4 cancer clinical trial;
3.
The treatment is being provided as part of a study being conducted in accordance with a clinical trial approved by at least one of the following: (a) One of the National Institutes of Health; (b) A National Institutes of Health Cooperative Group or Center; (c) The United States Food and Drug Administration in the form of an investigational new drug application;(d) The United States 40 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
Department of Defense; (e) The United States Department of Veteran Affairs; (f) a qualified research entity that meets the criteria established by the National Institutes of Health for grant eligibility; or (g) a panel of qualified recognized experts in clinical research within academic health institutions in the State of Arizona;
4.
The proposed treatment or study has been reviewed and approved by an institutional review board of an institution in the State of Arizona;
5.
The personnel providing the treatment or conducting the study (a) are providing the treatment or conducting the study within their scope of practice, experience and training and are capable of providing the treatment because of their experience, training and volume of patients treated to maintain expertise;(b) agree to accept reimbursement as payment in full from the Plan at the rates that are established by the Plan and that are not more than the level of reimbursement applicable to other similar services provided by the health care providers with the Plan’s network;
6.
There is no clearly superior, non-investigational treatment alternative;
7.
The available clinical or pre-clinical data provide a reasonable expectation that the treatment will be at least as efficacious as any non-investigational alternative;
For the purposes of this specific covered service and benefit, coverage outside the State of Arizona will be provided under the following conditions:
(a) The clinical trial treatment is curative in nature; (b) The treatment is not available through a clinical trial in the State of Arizona; (c) There is no other non-investigational treatment alternative;
For the purposes of this specific covered service and benefit, the following definitions apply:
1.
“Cooperative Group” – means a formal network of facilities that collaborates on research projects and that has an established national institutes of health approved peer review program operating within the group, including the National Cancer Institute Clinical Cooperative Group and The National Cancer Institute Community Clinical Oncology Program.
2.
“Institutional Review Board” – means any board, committee or other group that is both: (a) formally designated by an institution to approve the initiation of and to conduct periodic review of biomedical research involving human subjects and in which the primary purpose of such review is to assure the protection of the 41 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
rights and welfare of the human subjects and not to review a clinical trial for scientific merit; and (b) approved by the National Institutes of Health Office for Protection From Research Risks.
3.
“Multiple Project Assurance Contract” – means a contract between an institution and the United States Department of Health and Human Services that defines the relationship of the institution to the United States Department of Health and Human Services and that sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human subjects.
4.
“Patient Cost” – means any fee or expense that is covered under the Plan and that is for a service or treatment that would be required if the patient were receiving usual and customary care.
Patient cost does not include the cost: (a) of any drug or device provided in a phase I cancer clinical trial; (b) of any investigational drug or device; (c) of non-health services that might be required for a person to receive treatment or intervention; (d) of managing the research of the clinical trial; (e) that would not be covered under the Plan; and (f) of treatment or services provided outside the State of Arizona.
7.16.
Chiropractic Care Services
Chiropractic care services include diagnostic and treatment services utilized in an office setting by Participating chiropractic Physicians and Osteopaths. Chiropractic treatment includes the conservative management of neuromusculoskeletal conditions through manipulation and ancillary physiological treatment rendered to specific joints to restore motion, reduce pain and improve function.
The following are specifically excluded from chiropractic care and osteopathic services:
1.
Services of a chiropractor or osteopath which are not within his scope of practice, as defined by state law;
2.
Charges for care not provided in an office setting;
3.
Maintenance or preventive treatment consisting of routine, long term or non-Medically Appropriate care provided to prevent reoccurrences or to maintain the patient’s current status; and
4.
Vitamin therapy.
Services are limited to twenty (20) visits per Member per Plan year.
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7.17.
Cosmetic Surgery
Cosmetic Surgery is covered for reconstructive surgery that constitutes necessary care and treatment of medically diagnosed services required for the prompt repair of accidental injury. Congenital defects and birth abnormalities are covered for Eligible Dependent children.
7.18.
Dental Confinements/Anesthesia
Facility and anesthesia services for hospitalization in connection with dental or oral surgery will be covered, provided that the confinement has been Pre-Authorized because of a hazardous medical condition. Such conditions include heart problems, diabetes, hemophilia, dental extractions due to cancer related conditions, and the probability of allergic reaction (or any other condition that could increase the danger of anesthesia). All facility services must be provided by a contracted network provider.
7.19.
Dental Services – Accident only
Dental services are covered for the treatment of a fractured jaw or an Injury to sound natural teeth. Benefits are payable for the services of a Physician, dentist, or dental surgeon, provided the services are rendered for treatment of an Accidental Injury to sound natural teeth where the continuous course of treatment is started within six (6) months of the accident.
Sound natural teeth are defined as natural teeth that are free of active clinical decay, have at least 50% bony support, and are functional in the arch.
7.20.
Diabetic Service and Supplies
Coverage will be provided for the following Medically Appropriate supplies, devices, and appliances prescribed by a health care provider for the treatment of diabetes:
1.
Podiatric/ appliances for prevention of complications associated with diabetes; foot orthotic devices and inserts (therapeutic shoes: including Depth shoes or Custom Molded shoes.) Custom molded shoes will only be covered when the member has a foot deformity that cannot be accommodated by a depth shoe. Therapeutic shoes are covered only for diabetes mellitus and any of the following complications involving the foot: Peripheral neuropathy with evidence of callus formation; or history of pre-ulcerative calluses; or history of previous ulceration; or foot deformity; or previous amputation of the foot or part of the foot; 43 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
or poor circulation. Definitions of Depth shoes and custom molded shoes are as follows:
⎯
Depth Shoes shall mean the shoe has a full length, heel-to-toe filler that, when removed, provides a minimum of 3/16th inch of additional depth used to accommodate custom-molded or customized inserts; are made of leather or other suitable material of equal quality; have some sort of shoe closure; and are available in full and half sizes with a minimum of three widths so that the sole is graded to the size and width of the upper portions of the shoes according to the American standard sizing schedule or its equivalent.
⎯
Custom-molded shoes shall mean constructed over a positive model of the member’s foot; made from leather or other suitable material of equal quality; have removable inserts that can be altered or replaced as the member’s condition warrants; and have some sort of shoe closure. This includes a shoe with or without an internally seamless toe.
2.
Any other device, medication, equipment or supply for which coverage is required under Medicare guidelines pertaining to diabetes management; and
3.
Charges for training by a Physician, including a podiatrist with recent education in diabetes management, but limited to the following:
a.
Medically Appropriate visits when diabetes is diagnosed;
b.
Visits following a diagnosis of a significant change in the symptoms or conditions that warrant change in self-management;
c.
Visits when reeducation or refresher training is prescribed by the Physician; and
d.
Medical nutrition therapy (education) related to diabetes management.
7.21.
Diagnostic testing, including Laboratory and Radiology Services
Diagnostic testing includes radiological procedures, laboratory tests, and other diagnostic procedures.
7.22.
Durable Medical Equipment
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The wording contained within this Plan Description may be revised at any time for
Purchase or rental of durable medical equipment is covered when ordered or prescribed by a Participating Physician and provided by a vendor approved by the Plan. The determination to either purchase or rent equipment will be made by the Medical Management Organization. Coverage for repair, replacement or duplicate equipment is not covered clarification purposes without prior notice.
except when replacement or revision is necessary due to anatomical growth or a change in medical condition.
Durable medical equipment is defined as:
1.
Generally for the medical or surgical treatment of an Illness or Injury, as certified in writing by the attending medical provider;
2.
Serves a therapeutic purpose with respect to a particular Illness or Injury under treatment in accordance with accepted medical practice;
3.
Items which are designed for and able to withstand repeated use by more than one person;
4.
Is of a truly durable nature;
5.
Appropriate for use in the home; and
6.
Is not useful in the absence of Illness or Injury.
Such equipment includes, but is not limited to, crutches, hospital beds (to maximum of $5,000 annually), wheel chairs, respirators, and dialysis machines.
Unless covered in connection with the services described in the "Inpatient Services at Other Participating Health Care Facilities" or "Home Health Services" provisions, the following are specifically excluded:
1.
Hygienic or self-help items or equipment;
2.
Items or equipment primarily used for comfort or convenience such as bathtub chairs, safety grab bars, stair gliders or elevators, over-the-bed tables, saunas or exercise equipment;
3.
Environmental control equipment, such as air purifiers, humidifiers and electrostatic machines;
4.
Institutional equipment, such as air fluidized beds and diathermy machines;
5.
Elastic stockings and wigs;
6.
Equipment used for the purpose of participation in sports or other recreational activities including, but not limited to, foot orthotics, braces and splints;
7.
Items, such as auto tilt chairs, paraffin bath units and whirlpool baths, which are not generally accepted by the medical profession as being therapeutically effective; and
8.
Items which under normal use would constitute a fixture to real property, such as lifts, ramps, railings, and grab bars.
9.
Hearing aid batteries (except those for cochlear implants) and chargers.
45 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
7.23.
External Prosthetic Appliances
The Plan covers the initial purchase and fitting of external prosthetic devices which are used as a replacement or substitute for a missing body part and are necessary for the alleviation or correction of illness, injury or congenital defect. External prosthetic appliances shall include artificial arms and legs, hearing aids and terminal devices such as a hand or hook. Replacement of external prosthetic appliances (except for hearing aids) is covered only if necessitated by normal anatomical growth or as a result of wear and tear.
The following are specifically excluded:
1.
Any biomechanical devices. Biomechanical devices are any external prosthetics operated through or in conjunction with nerve conduction or other electrical impulses;
2.
Replacement of external prosthetic appliances due to loss or theft; and
3.
Wigs or hairpieces.
7.24.
Family Planning Services (Contraception and Voluntary Sterilization)
Covered family planning services including:
1.
Medical history;
2.
Physical examination;
3.
Related laboratory tests;
4.
Medical supervision in accordance with generally accepted medical practice;
5.
Information and counseling on contraception;
6.
Implanted/injected contraceptives; and
7.
After appropriate counseling, Medical Services connected with surgical therapies (vasectomy or tubal ligation).
7.25.
Foot Orthotics
The following foot orthotics are covered by the plan for treatment of diabetes see 7.20. Diabetic Services and Supplies:
Custom-molded shoes constructed over a positive model of the member’s foot made from leather or other suitable material of equal quality containing removable inserts that can be altered or replaced as the member’s condition warrants and have some sort of shoe closure. This includes a shoe with or without an internally seamless toe.
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clarification purposes without prior notice.
7.26.
Hearing Aids
Hearing aid services limited to $1,500 for each ear per Member, per Plan Year. The following services are covered:
•
New or replacement hearing aids no longer under warranty (pre-certification required).
•
Cleaning or repair
•
Batteries for cochlear implants
7.27.
Home Health Services
Home health services limited to a maximum of 42 visits per member per plan year are covered when the following criteria are met:
1.
The physician must have determined a medical need for home health care and developed a plan of care that is reviewed at thirty day intervals by the physician.
2.
The care described in the plan of care must be for intermittent skilled nursing, therapy, or speech services.
3.
The patient must be homebound.
4.
The home health agency delivering care must be certified within the state the care is received.
5.
The care that is being provided is not custodial care.
A Home Health visit is considered to be up to four hours of services. Home health services do not include services of a person who is a member of your family or your dependent’s family or who normally resides in your house or your dependent’s house. Physical, occupational, and speech therapy provided in the home are also subject to the 60 visit benefit limitations described under 7.52. Short-Term Rehabilitative Therapy.
7.28.
Hospice Services
The Plan covers hospice care services which are provided under an approved hospice care program when provided to a Member who has been diagnosed by a Participating Provider as having a terminal illness with a prognosis of six (6) months or less to live. Hospice care services include inpatient care; outpatient services; professional services of a Physician; services of a psychologist, social worker or family counselor for individual and family counseling; and home health services.
Hospice care services do not include the following:
1.
Services of a person who is a member of your family or your dependent's family or who normally resides in your house or your dependent's house;
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clarification purposes without prior notice.
2.
Services and supplies for curative or life prolonging procedures;
3.
Services and supplies for which any other benefits are payable under the Plan;
4.
Services and supplies that are primarily to aid you or your dependent in daily living;
5.
Services and supplies for respite (custodial) care; and
6.
Nutritional supplements, non-prescription drugs or substances, medical supplies, vitamins or minerals.
Hospice care services are services provided by a Participating Hospital; a Participating skilled nursing facility or a similar institution; a Participating home health care agency; a Participating hospice facility, or any other licensed facility or agency under a Medicare approved hospice care program.
A hospice care program is a coordinated, interdisciplinary program to meet the physical, psychological, spiritual and social needs of dying persons and their families; a program that provides palliative and supportive medical, nursing, and other health services through home or inpatient care during the illness; and a program for persons who have a terminal illness and for the families of those persons.
A hospice facility is a Participating institution or portion of a facility which primarily provides care for terminally ill patients; is a Medicare approved hospice care facility; meets standards established by the Plan; and fulfills all licensing requirements of the state or locality in which it operates.
7.29.
Immunizations
Immunizations are not subject to the annual routine maximum benefit.
Covered immunizations for adults and children over age 2 include:
1.
Influenza, Trivalent inactivated influenza vaccine (TIV)
2.
Influenza, Live attenuated influenza vaccine (LAIV)
3.
Pneumococcal
4.
Hepatitis B (Hep B)
5.
Hepatitis A (Hep A)
6.
Td (Tetanus, diphtheria)
7.
Polio (IPV)
8.
Varicella (Var)
9.
Meningococcal Conjugate vaccine (MCV4)
10.
MMR (Measles, mumps, rubella)
11.
HPV Vaccine, Gardasil
12.
Shingles Vaccine, Zoster
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clarification purposes without prior notice.
13.
Other immunizations approved by the plan.
7.30.
Inpatient Services at Other Participating Health Care Facilities
Inpatient services include semi-private room and board; skilled and general nursing services; Physician visits; physiotherapy; speech therapy; occupational therapy; x-rays; and administration of drugs, medications, biologicals and fluids.
7.31.
Insulin Pumps and Supplies
Insulin pumps and insulin pump supplies are covered when ordered by a Physician and obtained through a contracted durable medical equipment supplier. You may call the Customer Service number on your ID card if you need assistance locating a contracted supplier.
7.32.
Internal Prosthetic/Medical Appliances
Internal prosthetic/medical appliances are prosthetics and appliances that are permanent or temporary internal aids and supports for non-functional body parts, including testicular implants following Medically Appropriate surgical removal of the testicles. Medically Appropriate repair, maintenance or replacement of a covered appliance is covered.
7.33.
Mammograms
Mammograms are covered for routine and diagnostic breast cancer screening as follows:
1.
A single baseline mammogram if you are age 35-39;
2.
Once per Plan Year if you are age 40 and older.
7.34.
Maternity Care Services
Maternity care services include medical, surgical and hospital care during the term of pregnancy, upon delivery and during the postpartum period for normal delivery, cesarean section, spontaneous abortion (miscarriage), complications of pregnancy, and maternal risk. Inpatient maternity delivery is subject to a $250.00 maternity delivery co-payment per child. The $250.00 co-payment will be reimbursed if the member enrolls in the health pregnancy program prior to the 12th week of pregnancy and completes the program.
Coverage for a mother and her newly born child shall be available for a minimum of forty-eight (48) hours of inpatient care following a vaginal delivery and a minimum of ninety-six (96) hours of inpatient care following a cesarean section. Any decision to shorten the period of
49 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
inpatient care for the mother or the newborn must be made by the attending Physician in consultation with the mother.
These maternity care benefits also apply to the natural mother of a newborn child legally adopted by you in accordance with the Plan adoption policies.
These benefits do not apply to the newly born child of an Eligible Dependent daughter unless placement with the Employee is confirmed through a court order or legal guardianship.
Charges incurred at the birth for the delivery of a child only to the extent that they exceed the birth mother’s coverage, if any, provided:
1.
That child is legally adopted by you within one year from date of birth;
2.
You are legally obligated to pay the cost of the birth;
3.
You notify the Plan of the adoption within 60 days after approval of the adoption or a change in the insurance policies, plans or company; and
4.
You choose to file a claim for such expenses subject to all other terms of these medical benefits.
7.35.
Medical Foods / Metabolic Supplements and Gastric Disorder Formula
Medical foods, metabolic supplements and Gastric Disorder Formula to treat inherited metabolic disorders or a permanent disease/non-functioning condition in which a Member is unable to sustain weight and strength commensurate with the Member’s overall health status are covered.
Inherited metabolic disorders triggering medical food coverage are:
1.
Part of the newborn screening program as prescribed by Arizona statute; involve amino acid, carbohydrate or fat metabolism;
2.
Have medically standard methods of diagnosis, treatment and monitoring including quantification of metabolites in blood, urine or spinal fluid or enzyme or DNA confirmation in tissues; and
3.
Require specifically processed or treated medical foods that are generally available only under the supervision and direction of a physician, that must be consumed throughout life and without which the person may suffer serious mental or physical impairment.
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clarification purposes without prior notice.
For non-inherited disorders, enteral nutrition is considered Medically Appropriate when the Member has:
1.
A permanent non-function or disease of the structures that normally permit food to reach the small bowel; or
2.
A disease of the small bowel which impairs digestion and absorption of an oral diet consisting of solid or semi-solid foods.
The Plan will cover up to 75% of the cost of medical foods prescribed to treat metabolic disorders covered under this Plan. There is a maximum Plan Year limit for medical foods of $20,000 which applies to the cost of all prescribed modified low protein foods and metabolic formula.
For the purpose of this section, the following definitions apply:
“Inherited Metabolic Disorder” means a disease caused by an inherited abnormality of body chemistry and includes a disease tested under the newborn screening program as prescribed by Arizona statute. Medical Foods means modified low protein foods and metabolic formula.
“Metabolic Formula” means foods that are all of the following:
1.
Formulated to be consumed or administered internally under the supervision of a medical doctor or doctor of osteopathy;
2.
Processed or formulated to be deficient in one or more of the nutrients present in typical foodstuffs;
3.
Administered for the medical and nutritional management of a person who has limited capacity to metabolize foodstuffs or certain nutrients contained in the foodstuffs or who has other specific nutrient requirements as established by medical evaluation; and
4.
Essential to a person’s optimal growth, health and metabolic homeostasis.
“Modified Low Protein Foods” means foods that are all of the following: formulated to be consumed or administered internally under the supervision of a medical doctor or doctor of osteopathy:
1.
Processed or formulated to contain less than one gram of protein per unit of serving, but does not include a natural food that is naturally low in protein;
2.
Administered for the medical and nutritional management of a person who has limited capacity to metabolize foodstuffs or certain nutrients contained in the foodstuffs or who has other 51 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
specific nutrients requirements as established by medical evaluation; and
3.
Essential to a person’s optimal growth, health and metabolic homeostasis.
The following are not considered Medically Appropriate and are not covered as a Metabolic Food / Metabolic Supplement and Gastric Disorder Formula:
1.
Standard oral infant formula;
2.
Food thickeners, baby food, or other regular grocery products;
3.
Nutrition for a diagnosis of anorexia; and
4.
Nutrition for nausea associated with mood disorder, end-stage disease, etc.
7.36.
Medical Supplies
Medical supplies include Medically Appropriate supplies which may be considered disposable, however, are required for a Member in a course of treatment for a specific medical condition. Supplies must be obtained from a Participating Provider. Over the counter supplies, such as band-aids and gauze are not covered.
7.37.
Mental Health and Substance Abuse Services
Mental Health Services are those services that are required to treat a disorder that impairs the behavior, emotional reaction or thought processes. In determining benefits payable, charges made for the treatment of any physiological conditions related to mental health will not be considered to be charges made for treatment of mental health.
Substance Abuse is defined as the psychological or physical dependence on alcohol or other mind-altering drugs that requires diagnosis, care, and treatment. In determining benefits payable, charges made for the treatment of any conditions of physiological instability requiring medical hospitalization will not be considered to be charges made for treatment of substance abuse.
7.38.
Inpatient Mental Health Services
Inpatient Mental Health Services are services that are provided by a Participating Hospital for the treatment and evaluation of mental health during an inpatient admission.
7.39.
Outpatient Mental Health Services
Outpatient Mental Health Services are services by Participating Providers who are qualified to treat mental health when treatment is
52 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
provided on an outpatient basis in an individual, group or structured group therapy program. Covered services include, but are not limited to, outpatient treatment of conditions such as: anxiety or depression which interferes with daily functioning; emotional adjustment or concerns related to chronic conditions, such as psychosis or depression; neuropsychological testing; emotional reactions associated with marital problems or divorce; child/adolescent problems of conduct or poor impulse control; affective disorders; suicidal or homicidal threats or acts; eating disorders; or acute exacerbation of chronic mental health conditions (crisis intervention and relapse prevention), outpatient testing/assessment, and medication management when provided in conjunction with a consultation.
7.40.
Outpatient Substance Abuse Rehabilitation Services
Outpatient substance abuse services include services for the diagnosis and treatment of abuse or addiction to alcohol and/or drugs including outpatient rehabilitation in an individual, group, structured group or intensive outpatient structured therapy program. Intensive outpatient structured therapy programs consist of distinct levels or phases of treatment that are provided by a certified/licensed substance abuse program. Intensive outpatient structured therapy programs provide nine or more hours of individual, family and/or group therapy in a week.
7.41.
Residential Substance Abuse Treatment
Voluntary and court-ordered residential substance abuse treatment will be covered for a maximum of 90 days and limited to two treatments per plan year for chemical and alcohol dependency.
7.42.
Substance Abuse Detoxification Services
Substance abuse detoxification services include detoxification and related medical ancillary services when required for the diagnosis and treatment of addiction to alcohol and/or drugs, and medication management when provided in conjunction with a consultation. The Medical Management Organization will decide, based on the Medical Necessity of each situation, whether such services will be provided in an inpatient or outpatient setting. In-patient detoxification coverage is limited to two treatments per year and a lifetime maximum of five.
7.43.
Excluded Mental Health and Substance Abuse Services
The following are specifically excluded from mental health and substance abuse services:
1.
Any court ordered treatment or therapy, or any treatment or therapy ordered as a condition of parole, probation or custody 53 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
or visitation evaluations unless Medically Appropriate and otherwise covered under this Plan;
2.
Treatment of mental disorders that have been diagnosed as organic mental disorders associated with permanent dysfunction of the brain;
3.
Treatment of Chronic Conditions not subject to favorable modification according to generally accepted standards of medical practice;
4.
Developmental disorders, including but not limited to:
a.
developmental reading disorders;
b.
developmental arithmetic disorders;
c.
developmental language disorders; or
d.
articulation disorders.
5.
Counseling for activities of an educational nature;
6.
Counseling for borderline intellectual functioning;
7.
Counseling for occupational problems;
8.
Counseling related to consciousness raising;
9.
Vocational or religious counseling;
10.
I.Q. testing;
11.
Residential treatment; (unless associated with chemical or alcohol dependency as described in the Residential Substance Abuse Treatment provisions)
12.
Marriage counseling;
13.
Custodial care, including but not limited to geriatric day care;
14.
Psychological testing on children requested by or for a school system; and
15.
Occupational/recreational therapy programs even if combined with supportive therapy forage-related cognitive decline.
16.
Biofeedback is not covered for reasons other than pain management.
7.44.
Nutritional Evaluation
Nutritional evaluation and counseling from a Participating Provider is covered when diet is a part of the medical management of a documented organic disease, including morbid obesity.
All other services for the purpose of diet control and weight reduction are not covered unless required by a specifically identified condition of disease etiology. Services not covered include but not limited to: gastric surgery, intra oral wiring, gastric balloons, dietary formulae, hypnosis, cosmetics, and health and beauty aids.
54 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
7.45.
Obstetrical and Gynecological Services
Obstetrical and gynecological services are covered when provided by qualified Participating Providers for pregnancy, well-women gynecological exams, primary and preventive gynecological care and acute gynecological conditions.
7.46.
Organ Transplant Services
Human organ and tissue transplant services are covered at designated facilities throughout the United States. This coverage is subject to the following conditions and limitations. Due to the specialized medical care required for transplants, the Provider Network for this specific service may not be the same as the medical network in which you enrolled.
These benefits are only available when the Member is the recipient of an organ transplant. No benefits are available where the Member is an organ donor for a recipient other than a Member enrolled on the same family policy.
Organ transplant services include the recipient’s medical, surgical and hospital services; inpatient immunosuppressive medications; and costs for organ procurement. Transplant services are covered only if they are required to perform human to human organ or tissue transplants, such as:
1.
Allogeneic bone marrow/stem cell;
2.
Autologous bone marrow/stem cell;
3.
Cornea;
4.
Heart;
5.
Heart/lung;
6.
Kidney;
7.
Kidney/pancreas;
8.
Liver;
9.
Lung;
10.
Pancreas; or
11.
Small bowel/liver
12.
Kidney/liver
Organ transplant coverage will apply only to non-experimental transplants for the specific diagnosis. All organ transplant services other than cornea, kidney and autologous bone marrow/stem cell transplants must be received at a qualified organ transplant facility.
Coverage for organ procurement costs are limited to costs directly related to the procurement of an organ, from a cadaver or a live donor. Organ procurement costs shall consist of surgery necessary for organ
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clarification purposes without prior notice.
removal, organ transportation and the transportation, hospitalization and surgery of a live donor. Compatibility testing undertaken prior to procurement is covered if Medically Necessary.
7.47.
Organ Transplant Travel Services
Travel expenses incurred by the Member in connection with a pre-approved organ/tissue transplant are covered subject to the following conditions and limitations. Travel expenses are limited to $10,000. Organ transplant travel benefits are not available for cornea transplants. Benefits for transportation, lodging and food are available only for the recipient of a pre-approved organ/tissue transplant from a transplant facility. The term recipient is defined to include a Member receiving authorized transplant related services during any of the following:
1.
Evaluation,
2.
Candidacy,
3.
Transplant event, or
4.
Post-transplant care.
All claims filed for travel expenses must include detailed receipts, except for mileage. Transportation mileage will be calculated by the Third Party Claim Administrator based on the home address of the Member and the transplant site. Travel expenses for the Member receiving the transplant will include charges for:
1.
Transportation to and from the transplant site (including charges for a rental car used during a period of care at the transplant facility);
2.
Transportation to and from the transplant site in a personal vehicle will be reimbursed at 37.5 cents per mile when the transplant site is more than 60 miles one way from the Member’s home.
3.
Lodging while at, or traveling to and from the transplant site;
4.
Food while at, or traveling to and from the transplant site.
In addition to the Member being covered for the charges associated with the items above, such charges will also be considered covered travel expenses for one companion to accompany the Member. The term companion includes your spouse, a member of your family, your legal guardian, or any person not related to you, but actively involved as your caregiver.
The following are specifically excluded travel expenses:
56 AZ Benefit Options – EPO 100109V6
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clarification purposes without prior notice.
1.
Travel costs incurred due to travel within 60 miles of your home;
2.
Laundry bills;
3.
Telephone bills;
4.
Alcohol or tobacco products; and
5.
Charges for transportation that exceed coach class rates.
7.48.
Ostomy Supplies
Ostomy supplies are supplies which are medically appropriate for care and cleaning of a temporary or permanent ostomy. Covered supplies include, but are not limited to pouches, face plates and belts, irrigation sleeves, bags and catheters, skin barriers, gauze, adhesive, adhesive remover, deodorant, pouch covers, and other supplies as appropriate.
7.49.
Oxygen and the Oxygen Delivery System.
Coverage of oxygen that is routinely used on an outpatient basis is limited to coverage within the Service Area. Oxygen Services and Supplies are not covered outside of the Service Area, except on an emergency basis.
7.50.
Periodic Routine Health Examinations
Well Child visits and immunizations are covered through 23 months as recommended by the American Academy of Pediatrics.
Well woman exams are covered in addition to periodic health exams. Covered expenses include an annual office visit and one Papanicolaou test (PAP smear). Laboratory charges are covered as a separate expense. Limited to 1 visit per Member per Plan Year.
Well man exams are covered in addition to periodic health exams. Covered expenses include an annual office visit with prostate-specific antigen (PSA) test. Laboratory charges are covered as a separate expense. Limited to 1 visit per Member per Plan Year.
Periodic routine health examinations age 2 and over by a physician limited to one (1) visit per Member per Plan Year and $1500 maximum benefit paid per Member per Plan Year. To include laboratory, radiology services, routine vision, and hearing screening, provided by a Physician.
Well child, well woman, and well man exams do not apply to the stated periodic routine health examination limits.
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clarification purposes without prior notice.
7.51.
Radiation Therapy
Radiation therapy and other therapeutic radiological procedures are covered.
7.52.
Short-term Rehabilitative Therapy
Short-term rehabilitative therapy includes services in an outpatient facility or physician’s office that is part of a rehabilitation program, including physical, speech, occupational, cardiac rehabilitation and pulmonary rehabilitation therapy. Covered expenses are limited to sixty (60) visits per Member per Plan Year additional visits subject to medical necessity with pre-certification.
The following limitations apply to short-term rehabilitative therapy:
1.
Occupational therapy is provided only for purposes of training Members to perform the activities of daily living.
2.
Speech therapy is not covered when:
a.
Used to improve speech skills that have not fully developed;
b.
Considered custodial or educational;
c.
Intended to maintain speech communication; or
d.
Not restorative in nature.
3.
Phase 3 cardiac rehabilitation is not covered.
If multiple services are provided on the same day by different Providers, a separate Co-payment will apply to each Provider.
7.53.
Surgical Procedures – Multiple/Bilateral
Multiple or Bilateral Surgical Procedures performed by one or more qualified physicians during the same operative session will be covered according to the following guidelines:
1.
The lesser of the actual charges, Reasonable and Customary amount, or the contracted fee as determined by the Provider’s contract with the Network will be allowed for the primary Surgical Procedure.
2.
50% of the lesser of the actual charges, Reasonable and Customary amount, or the contracted fee as determined by the Provider’s contract with the Network (not to exceed the actual charge) will be allowed for the secondary Surgical Procedure.
7.54.
Temporomandibular Joint (TMJ) Disorder
Benefits are payable for covered services and supplies which are necessary to treat TMJ disorder which is a result of:
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clarification purposes without prior notice.
1.
An accident;
2.
Trauma;
3.
A congenital defect;
4.
A developmental defect; or
5.
A pathology.
Covered expenses include diagnosis and treatment of TMJ that is recognized by the medical or dental profession as effective and appropriate treatment for TMJ, including intra-oral splints that stabilize the jaw joint.
Orthognathic treatment/surgery, dental and orthodontic services and/or appliances that are orthodontic in nature or change the occlusion of the teeth (external or intra-oral) are not covered.
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clarification purposes without prior notice.
ARTICLE 8
PRESCRIPTION DRUG BENEFITS
8.1.
Prescription Drug Benefit
If a Member incurs expenses for charges made by a Pharmacy for Covered Prescription Drugs, the Plan will pay a portion of the expense remaining after you have paid the required Co-payment shown in the Schedule of Benefits. The Prescription Drug Benefits are provided through the Plan Sponsor and administered by the Pharmacy Benefit Management vendor, an organization which has been contracted by the Plan Sponsor to perform these services.
The Member must pay a portion of Covered Prescription Drugs to receive Prescription Drug Benefits. That portion is described below. The Prescription Drug Co-payment is not considered an Eligible Expense under the medical portion of this Plan and do not accrue to the medical Plan Maximum Out-of-Pocket.
Dispense As Written or “DAW” are the rules associated with how the plan will pay for a name-brand prescription that has a generic equivalent. There are two rules related to this coverage “DAW1” and “DAW2”.
DAW1 – The drug is available as a generic, but the physician has requested that the brand be dispensed to the member. The member will be responsible for a generic co-pay plus the difference in cost between the brand drug and the generic drug.
DAW2 – The drug is available as a generic, but the member has requested that the brand be dispensed. The member will be responsible for a generic copay plus the difference in cost between the brand drug and the generic drug.
To avoid additional cost above the co-payment amounts members should ask their doctor to prescribe any available generic equivalent medications.
The Preferred Medication List (PML), also known as a formulary, is a list of medications that will allow you to maximize the value of your prescription benefit. These medications, chosen by a committee of doctors and pharmacists, are lower-cost generics and brand names that are available at a lower cost than their more expensive brand-name
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counterparts. The PML is updated quarterly, and as needed throughout the year to add significant new medications as they become available. Medications that no longer offer the best therapeutic value for the plan are deleted from the PML once a year, and a letter is sent to any member affected by the change. To see what medications are on the PML, log on to the PBM website or contact the Customer Service Center listed on your ID card. You may have a copy sent to you. Sharing this information with your doctor helps ensure that you are getting the medications you need, and saving money for both you and your plan.
CO-PAYMENT is that portion of Covered Prescription Drugs which you are required to pay under this benefit. In addition to the co-payments outlined below, members will be required to pay the difference in the medication cost of a generic medication versus a name-brand medication when the member requests the brand name drug and the prescribing physician has indicated the generic equivalent substitution is allowable. The plan will exclude Narrow Therapeutic Index (NTI) drugs from the co-pay penalties.
PARTICIPATING RETAIL PHARMACY CO-PAYMENT (up to a 30-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $10
For Formulary Brand-Name Drugs $20
For Non-Formulary Brand-Name Drugs $40
PARTICIPATING MAIL ORDER PHARMACY CO-PAYMENT (up to a 90-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $20
For Formulary Brand-Name Drugs $40
For Non-Formulary Brand-Name Drugs $80
PARTICIPATING RETAIL CO-PAYMENT (up to a 90-day supply)
An amount as follows for each Prescription Order:
For Generic Drugs $25
For Formulary Brand-Name Drugs $50
For Non-Formulary Brand-Name Drugs $100
No payment will be made under any other section for expenses incurred to the extent that benefits are payable for those expenses under this section.
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8.2.
Covered Prescription Drugs
The term Covered Prescription Drugs means:
1.
A Prescription Legend Drug for which a written prescription is required. A Legend Drug is one which has on its label "caution: federal law prohibits dispensing without a prescription";
2.
Insulin; pre-filled insulin cartridges for the blind; oral blood sugar control agents;
3.
Needles, syringes, glucose monitors, and machines, glucose test strips, visual reading ketone strips; urine test strips, lancets and alcohol swaps are all covered when dispensed by the mail order and retail pharmacy program;
4.
A compound medication of which at least one ingredient is a Prescription Legend Drug;
5.
Tretinoin for individuals through age 24;
6.
Any other drug which, under the applicable state law, may be dispensed only upon the written prescription of a Physician;
7.
Oral contraceptives or contraceptive devices, regardless of intended use, except that implantable contraceptive devices, such as Norplant, are not considered Covered Prescription Drugs;
8.
Prenatal vitamins, upon written prescription;
9.
Growth hormones; (with prior-authorization); or
11. Injectable drugs or medicines for which a prescription is required, except injectable infertility drugs.
8.3.
Limitations
No payment will be made for expenses incurred for the following:
1.
For non-legend drugs, other than those specified under ‘‘Covered Prescription Drugs’’;
2.
To the extent that payment is unlawful where the person resides when expenses are incurred;
3.
For charges which the person is not legally required to pay;
4.
For charges which would not have been made if the person were not covered by these benefits;
5.
For experimental drugs or for drugs labeled: ‘‘Caution limited by federal law to investigational use’’;
6.
For drugs which are not considered essential for the necessary care and treatment of a non-occupational Injury or Sickness, as determined by the Plan Administrator;
7.
For drugs obtained from a non-Participating Pharmacy;
62 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
8.
For any prescription filled in excess of the number specified by the Physician or dispensed more than one year from the date of the Physician’s order;
9.
For more than a 30-day supply when dispensed in any one Prescription Order through a Retail Pharmacy;
10.
For more than a 90-day supply when dispensed in any one Prescription Order through a Participating Mail-Order Pharmacy;
11.
For indications not approved by the Food and Drug Administration;
12.
For immunization agents, biological sera, blood, or blood plasma;
13.
For therapeutic devices or appliances, support garments and other non-medicinal substances, excluding insulin syringes;
14.
For drugs for cosmetic purposes;
15.
For tretinoin for individuals age 25 and over;
16.
For administration of any drug;
17.
For medication which is taken or administered, in whole or in part, at the place where it is dispensed or while a person is a patient in an institution which operates, or allows to be operated on its premises, a facility for dispensing pharmaceuticals;
18.
For prescriptions which an eligible person is entitled to receive without charge from any workers’ compensation or similar law or any public program other than Medicaid;
19.
For non-Medically Appropriate anabolic steroids;
20.
For nutritional or dietary supplements, or anorexients;
21.
Implantable contraceptive devices;
22.
For prescription vitamins other than prenatal vitamins, upon
23.
written prescription;
24.
For all medications administered for the purpose of weight loss/obesity;
25.
For treatment of erectile or sexual dysfunction (both male and female); or
26.
For all injectable infertility drugs.
27.
Prescription medications that have over-the-counter (OTC) equivalents.
8.4.
Specialty Pharmacy
Certain medications used for treating chronic or complex health conditions are handled through the PBM’s Specialty Pharmacy Program.
63 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
The purpose of the Specialty Pharmacy Program is to assist you with monitoring your medication needs for conditions such as those listed below and providing patient education. The Program includes monitoring of specific injectable drugs and other therapies requiring complex administration methods, special storage, handling, and delivery.
clarification purposes without prior notice.
Medications for these conditions through this Specialty Pharmacy Program include but are not limited to the following:
1.
Cystic Fibrosis;
2.
Multiple Sclerosis;
3.
Rheumatoid Arthritis;
4.
Prostate Cancer;
5.
Endometriosis;
6.
Enzyme replacement;
7.
Precocious puberty;
8.
Osteoarthritis;
9.
Viral Hepatitis; or
10.
Asthma
Medications in the Specialty Program may only be obtained through contracted retail pharmacies store or through the PBM’s home delivery service. You may contact the PBM to determine which retail pharmacy’s are contracted. Specialty medications are limited to a 30-day supply.
A Specialty Care Representative may contact you to facilitate your enrollment in the Specialty Program. Trained Specialty Care pharmacy staff is available 24 hours a day, 7 days a week to assist you or you may enroll directly into the program by calling the PBM’s Customer Service Center.
8.5.
Reimbursement/Filing a Claim
If you or your Dependent purchases Covered Prescription Drugs from a Participating Retail Pharmacy, you pay only the portion shown in the Schedule of Benefits at the time of purchase for covered medications. Should you need to obtain a Covered Prescription Drug prior to obtaining your member ID card, you may file a claim form to obtain reimbursement. The claim form is available on the PBM’s website.
If you or your Dependent purchases Covered Prescription Drugs from a non-Participating Retail Pharmacy, you pay the full cost. These claims are considered not covered under any section of this Plan Description, unless the medication was obtained while traveling in a foreign country and was for an emergency. Claim forms and foreign travel guidelines are available on the PBM’s website.
64 AZ Benefit Options – EPO 100109V6
The wording contained within this Plan Description may be revised at any time for
clarification purposes without prior notice.
Travel Within the United States
International Travel
PBM Services
Benefits are co